MEDICARE: WELDON COOKE MD 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	261QP2300X	Primary Care Clinic/Center	01020627A	IN

General Provider Information

NPI Number	:	1528466091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELDON COOKE MD LLC

Provider Business Mailing Address
First Line	:	10176 W 400 N
Second Line	:	SUITE C
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-9008
Country	:	US
Telephone Number	:	219-873-1777
Fax Number	:	219-873-0001

Provider Business Practice Location Address
First Line	:	10176 W 400 N
Second Line	:	SUITE C
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-9008
Country	:	US
Telephone Number	:	219-873-1777
Fax Number	:	219-873-0001

Authorized Official
Title or Position	:	ADMIN
Name	:	TINA J BOWMAR
Credential	:
Telephone Number	:	219-221-7287

Provider Enumeration Date	:	12/15/2014
Last Update Date	:	12/15/2014

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Directions to “WELDON COOKE MD LLC ” Practice Location

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