Healthcare Provider Details

I. General information

NPI: 1568093557
Provider Name (Legal Business Name): COOK COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 W CHICAGO AVE
CHICAGO IL
60651-3342
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 773-826-9600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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