=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285168666
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD BLODGETT COOK D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2017
-----------------------------------------------------
Last Update Date | 08/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1577 CONGRESS ST STE 2
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04102-2169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-662-5522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1577 CONGRESS ST STE 2
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04102-2169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-662-5522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207SG0201X
-----------------------------------------------------
Taxonomy Name | Clinical Genetics (M.D.) Physician
-----------------------------------------------------
License Number | DO3776
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207SG0202X
-----------------------------------------------------
Taxonomy Name | Clinical Biochemical Genetics Physician
-----------------------------------------------------
License Number | DO3776
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------