Healthcare Provider Details

I. General information

NPI: 1528384567
Provider Name (Legal Business Name): DR. J. WESLEY COOK, D.O., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W ADDISON ST
CHICAGO IL
60618-6132
US

IV. Provider business mailing address

2001 W ADDISON ST
CHICAGO IL
60618-6132
US

V. Phone/Fax

Practice location:
  • Phone: 773-404-1000
  • Fax: 773-404-9750
Mailing address:
  • Phone: 773-404-1000
  • Fax: 773-404-9750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36080259
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number336043254
License Number StateIL

VIII. Authorized Official

Name: J WESLEY COOK
Title or Position: OWNER
Credential: D.O.
Phone: 773-404-1000