Healthcare Provider Details

I. General information

NPI: 1073097606
Provider Name (Legal Business Name): COOK COUNTY CCC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

1900 W POLK ST STE 220C
CHICAGO IL
60612-3723
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-4649
  • Fax:
Mailing address:
  • Phone: 312-864-4649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: SCOTT ANDRLE
Title or Position: DIRECTOR OF MANAGED CARE OPERATIONS
Credential:
Phone: 312-864-4649