Provider Demographics
NPI:1790731735
Name:ROOK, KEVIN WILLIAM
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:ROOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14372 RIVERBEND TRL
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-8433
Mailing Address - Country:US
Mailing Address - Phone:218-681-1046
Mailing Address - Fax:
Practice Address - Street 1:27040 COUNTY ROAD 9
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5456
Practice Address - Country:US
Practice Address - Phone:218-751-6405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1047318163W00000X
MNR104731-8367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN327342300Medicaid
MN327342300Medicaid
MN430007591Medicare PIN
MN430003745Medicare PIN