MEDICARE: MARK COCKLEY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1164551636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK COCKLEY, LLC

Provider Business Mailing Address
First Line	:	1 TURTLE CREEK CIR
Second Line	:	STE. F
City	:	SWANTON
State	:	OH
Zip	:	43558-8537
Country	:	US
Telephone Number	:	419-825-5151
Fax Number	:	419-825-5901

Provider Business Practice Location Address
First Line	:	1 TURTLE CREEK CIR
Second Line	:	STE. F
City	:	SWANTON
State	:	OH
Zip	:	43558-8537
Country	:	US
Telephone Number	:	419-825-5151
Fax Number	:	419-825-5901

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARK M COCKLEY
Credential	:	MD
Telephone Number	:	419-824-5063

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	01/28/2010

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