MEDICARE: DR. J WESLEY COOK D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	36080259	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	725326	OTHER	IL	HUMANA PROVIDER NUMBER
3	0586501	OTHER	IL	AETNA PROVIDER NUMBER
4	31604484	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1104814912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. J WESLEY COOK D.O.

Provider Business Mailing Address
First Line	:	4101 N RAVENSWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2193
Country	:	US
Telephone Number	:	773-285-6400
Fax Number	:	773-498-3096

Provider Business Practice Location Address
First Line	:	5801 W CORCORAN PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644
Country	:	US
Telephone Number	:	773-285-6400
Fax Number	:	773-498-3096

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	03/22/2023

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