Healthcare Provider Details

I. General information

NPI: 1760892020
Provider Name (Legal Business Name): BENJAMIN CHARLES COOK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 MACCORKLE AVE SE
CHARLESTON WV
25304-2224
US

IV. Provider business mailing address

5430 MACCORKLE AVE SE
CHARLESTON WV
25304-2224
US

V. Phone/Fax

Practice location:
  • Phone: 304-925-3627
  • Fax:
Mailing address:
  • Phone: 304-925-3627
  • Fax: 304-925-1163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27650
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: