Provider Demographics
NPI:1164471801
Name:COOK, ROGER TERRY (CP)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:TERRY
Last Name:COOK
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 NELMS RD
Mailing Address - Street 2:
Mailing Address - City:GRAYSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37338-4632
Mailing Address - Country:US
Mailing Address - Phone:423-949-8620
Mailing Address - Fax:423-949-9217
Practice Address - Street 1:87 NELMS RD
Practice Address - Street 2:
Practice Address - City:GRAYSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37338-4632
Practice Address - Country:US
Practice Address - Phone:423-949-8620
Practice Address - Fax:423-949-9217
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPRO0000000083224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4067689OtherBLUE CROSS BLUE SHIELD TN
TN1454290Medicaid
TN4735420001Medicare NSC