Provider Demographics
NPI:1710322987
Name:H. RUSSELL COOK, P.C.
Entity Type:Organization
Organization Name:H. RUSSELL COOK, P.C.
Other - Org Name:H. RUSSELL COOK, D.O.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:H.
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:334-393-1056
Mailing Address - Street 1:PO BOX 310210
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36331-0210
Mailing Address - Country:US
Mailing Address - Phone:334-393-1056
Mailing Address - Fax:334-393-6187
Practice Address - Street 1:207 E WATTS ST
Practice Address - Street 2:SUITE 220
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-1801
Practice Address - Country:US
Practice Address - Phone:334-393-1056
Practice Address - Fax:334-393-6187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO126261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000014819Medicaid
ALD32739Medicare UPIN