Healthcare Provider Details

I. General information

NPI: 1467875963
Provider Name (Legal Business Name): SUSAN COOK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VIKI BRAVO BILLING MANAGER

II. Dates (important events)

Enumeration Date: 02/04/2014
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 RIDGELY AVE SUITE 302
ANNAPOLIS MD
21401-1439
US

IV. Provider business mailing address

104 RIDGELY AVE SUITE 302
ANNAPOLIS MD
21401-1439
US

V. Phone/Fax

Practice location:
  • Phone: 410-280-9500
  • Fax: 443-214-5168
Mailing address:
  • Phone: 410-280-9500
  • Fax: 443-214-5168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberD0024768
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: