Healthcare Provider Details

I. General information

NPI: 1770213050
Provider Name (Legal Business Name): TYLER COOK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST # BI-2183
AUGUSTA GA
30912-0006
US

IV. Provider business mailing address

528 GRAY CATBIRD WAY
WARRENVILLE SC
29851-3095
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-0180
  • Fax:
Mailing address:
  • Phone: 540-312-9870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number13759
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: