Provider Demographics
NPI:1467875963
Name:COOK, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIKI
Other - Middle Name:
Other - Last Name:BRAVO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BILLING MANAGER
Mailing Address - Street 1:104 RIDGELY AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1439
Mailing Address - Country:US
Mailing Address - Phone:410-280-9500
Mailing Address - Fax:443-214-5168
Practice Address - Street 1:104 RIDGELY AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1439
Practice Address - Country:US
Practice Address - Phone:410-280-9500
Practice Address - Fax:443-214-5168
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0024768173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1548601883OtherGROUP NPI
MD1548601883OtherGROUP NPI