Basic Information
| Provider Information | |||||||||
| NPI: | 1275587354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | ALICE | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COOK | ||||||||
| OtherFirstName: | KATHY | ||||||||
| OtherMiddleName: | A. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 173891 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802179294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E BOULDER ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193656820 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2006 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | L8655 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 47141 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 181552401 | 05 | TX | MEDICAID | 8V2871 | 01 | TX | BCBS | OTHER | P00323527 | 01 | TX | RAILROAD | OTHER | 14135868 | 05 | CO | MEDICAID | 8V1344 | 01 | TX | BCBS | OTHER | 04978871 | 05 | NM | MEDICAID |