=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194908368
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. THOMAS COOKE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2007
-----------------------------------------------------
Last Update Date | 01/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1217 MELLEN ST
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98531-1175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-736-4021
-----------------------------------------------------
Fax | 360-736-3541
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1217 MELLEN ST
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98531-1175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-736-4021
-----------------------------------------------------
Fax | 360-736-3541
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. THOMAS R COOKE
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 360-736-4021
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OP00000823
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------