Basic Information
| Provider Information | |||||||||
| NPI: | 1386794113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECOOK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | ADAM | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HOWARD FARM DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300416081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702926500 | ||||||||
| FaxNumber: | 7702926535 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 HOWARD FARM DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300416081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702926500 | ||||||||
| FaxNumber: | 7702926535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 200301449 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207X00000X | 0101245422 | VA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 63576 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 509140519C | 05 | GA | MEDICAID | 557507 | 01 | GA | WELLCARE | OTHER | 89136RR | 05 | NC | MEDICAID | 9485152 | 01 | GA | AETNA | OTHER | 0101245422 | 01 | VA | LICENSE | OTHER | 509140519A | 05 | GA | MEDICAID | P01659745 | 01 | GA | RR MEDICARE | OTHER | 509140519O | 05 | GA | MEDICAID | 52241691 | 01 | GA | BCBS | OTHER | 7493615 | 01 | GA | CIGNA | OTHER | P00903599 | 01 | GA | MEDICARE RAILROAD | OTHER | 01353242 | 01 | GA | AMERIGROUP | OTHER | 509140519Q | 05 | GA | MEDICAID | BD8619794 | 01 | VA | DEA | OTHER | 509140519B | 05 | GA | MEDICAID | 509140519P | 05 | GA | MEDICAID | P01726634 | 01 | GA | RR MEDICARE | OTHER |