Healthcare Provider Details

I. General information

NPI: 1487734554
Provider Name (Legal Business Name): MAXWELL C COOKE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 CITY AVE N
RIPLEY MS
38663-1414
US

IV. Provider business mailing address

403 REEVES ST
NEW ALBANY MS
38652-4319
US

V. Phone/Fax

Practice location:
  • Phone: 662-837-9221
  • Fax: 662-837-2110
Mailing address:
  • Phone: 662-534-9834
  • Fax: 662-837-2110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMS05915
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: