Provider Demographics
NPI:1386065456
Name:COOK FOOT AND ANKLE SPECIALISTS LLC
Entity type:Organization
Organization Name:COOK FOOT AND ANKLE SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:B
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:435-752-9011
Mailing Address - Street 1:550 E 1400 N
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2406
Mailing Address - Country:US
Mailing Address - Phone:435-752-9011
Mailing Address - Fax:435-752-7159
Practice Address - Street 1:990 MEDICAL DR
Practice Address - Street 2:SUITE U3
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-4713
Practice Address - Country:US
Practice Address - Phone:435-734-9623
Practice Address - Fax:435-752-7159
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOK FOOT AND ANKLE SPECIALISTS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-17
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT72759630501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057765Medicare PIN