=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508891219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYNN SCOTT COOK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 10/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 W OAK ST STE 202
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62901-1464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-529-0555
-----------------------------------------------------
Fax | 618-529-0556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14717 N 740 EAST RD
-----------------------------------------------------
City | OAKWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61858-9410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-377-5768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | 036079723
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | 036079723
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------