Basic Information
| Provider Information | |||||||||
| NPI: | 1003966227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4107 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082338880 | ||||||||
| FaxNumber: | 2082321950 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 HOSPITAL WAY | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082391000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | M11396 | ID | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 11302 | MT | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | M11396 | 01 | ID | IDAHO MEDICAL LICENSE | OTHER | 11302 | 01 | MT | MONTANA LICENSE NUMBER | OTHER | 1003966227 | 05 | ID | MEDICAID |