Healthcare Provider Details

I. General information

NPI: 1396865077
Provider Name (Legal Business Name): COOK COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 S MICHIGAN AVE
CHICAGO IL
60653-1019
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 312-945-4010
  • Fax:
Mailing address:
  • Phone: 312-864-4649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number0004549
License Number StateIL

VIII. Authorized Official

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