Provider Demographics
NPI:1578767406
Name:COOKE, PETER H (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:H
Last Name:COOKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-4529
Mailing Address - Country:US
Mailing Address - Phone:517-371-1700
Mailing Address - Fax:517-268-6609
Practice Address - Street 1:1717 N HIGH ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-4529
Practice Address - Country:US
Practice Address - Phone:517-371-1700
Practice Address - Fax:517-268-6609
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2015-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPC049423208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1103312751OtherBCBS
MIPC049423OtherLIC #
MI3148943Medicaid
MI381779460OtherEIN
MIPC049423OtherLIC #
MI1103312751OtherBCBS