Healthcare Provider Details

I. General information

NPI: 1649551938
Provider Name (Legal Business Name): COOK COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2011
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15900 CICERO AVE
OAK FOREST IL
60452
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 312-864-4779
  • Fax: 312-864-9877
Mailing address:
  • Phone: 312-864-4649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number0005272
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0005272
License Number StateIL

VIII. Authorized Official

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