Basic Information
| Provider Information | |||||||||
| NPI: | 1356380273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 S HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067791290 | ||||||||
| FaxNumber: | 9067792154 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 S HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067791290 | ||||||||
| FaxNumber: | 9067792154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 04/01/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301043588 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 30387400 | 01 | WI | WISCONSIN MEDICAID | OTHER | 1429186 | 05 | MI | MEDICAID | 382396677017 | 01 | WI | WISCONSIN BCBS | OTHER |