Healthcare Provider Details

I. General information

NPI: 1003966227
Provider Name (Legal Business Name): ROGER A COOK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY
POCATELLO ID
83201-5175
US

IV. Provider business mailing address

PO BOX 4107
POCATELLO ID
83205-4107
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-1000
  • Fax:
Mailing address:
  • Phone: 208-233-8880
  • Fax: 208-232-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD-54947
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number11302
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberM11396
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: