Provider Demographics
NPI:1043360563
Name:COOK, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9605 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-2139
Mailing Address - Country:US
Mailing Address - Phone:313-834-5930
Mailing Address - Fax:
Practice Address - Street 1:9605 GRAND RIVER AVE.
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-2139
Practice Address - Country:US
Practice Address - Phone:313-834-5930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1306922554Medicaid
CA1265520183Medicaid
CA1841342318Medicaid