Basic Information
| Provider Information | |||||||||
| NPI: | 1518166289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W FAYETTE ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3159373433 | ||||||||
| FaxNumber: | 3154705859 | ||||||||
| Practice Location | |||||||||
| Address1: | 739 IRVING AVE | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154707364 | ||||||||
| FaxNumber: | 3154705859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2007 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 244186 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02901417 | 05 | NY | MEDICAID |