Healthcare Provider Details

I. General information

NPI: 1588669683
Provider Name (Legal Business Name): BRIAN COOK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 N MICHIGAN AVE STE 2310
CHICAGO IL
60611-2635
US

IV. Provider business mailing address

737 N MICHIGAN AVE STE 2310
CHICAGO IL
60611-2635
US

V. Phone/Fax

Practice location:
  • Phone: 312-266-6647
  • Fax: 312-266-6612
Mailing address:
  • Phone: 312-266-6647
  • Fax: 312-266-6612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036074309
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number036074309
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number036074309
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: