Healthcare Provider Details

I. General information

NPI: 1639175342
Provider Name (Legal Business Name): STEPHEN CHRISTOPHER COOK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5330 E STOP 11 RD
INDIANAPOLIS IN
46237-6345
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-893-1900
  • Fax: 317-893-1901
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01085224A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number4301109093
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207RA0002X
TaxonomyAdult Congenital Heart Disease Physician
License Number01085224A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: