MEDICARE: COOK COUNTY

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	000572	IL

General Provider Information

NPI Number	:	1598884629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COOK COUNTY

Provider Business Mailing Address
First Line	:	1900 W POLK ST RM 220C
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3723
Country	:	US
Telephone Number	:	312-864-4649
Fax Number	:

Provider Business Practice Location Address
First Line	:	4600 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60651-3342
Country	:	US
Telephone Number	:	773-826-9600
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF MANAGED CARE
Name	:	SCOTT ANDRLE
Credential	:
Telephone Number	:	312-864-4649

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	02/22/2019

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Directions to “COOK COUNTY ” Practice Location

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