Provider Demographics
NPI:1093948010
Name:W BRYCE COOK
Entity Type:Organization
Organization Name:W BRYCE COOK
Other - Org Name:FOOT CLINIC OF LOGAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:W
Authorized Official - Middle Name:BRYCE
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:#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:#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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-25
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1032580501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4243620002Medicare NSC