Healthcare Provider Details

I. General information

NPI: 1497875298
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: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 S. HARLEM AVE
RIVERSIDE IL
60546-1468
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 708-783-9800
  • 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 Number0005272
License Number StateIL

VIII. Authorized Official

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