MEDICARE: COOKE MEDICAL, LLC

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	207R00000X	Internal Medicine Physician		IL

General Provider Information

NPI Number	:	1326330853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COOKE MEDICAL, LLC

Provider Business Mailing Address
First Line	:	16750 80TH AVE
Second Line	:	STE A
City	:	TINLEY PARK
State	:	IL
Zip	:	60477-3173
Country	:	US
Telephone Number	:	877-815-6668
Fax Number	:	877-815-4960

Provider Business Practice Location Address
First Line	:	16750 80TH AVE
Second Line	:	STE A
City	:	TINLEY PARK
State	:	IL
Zip	:	60477-3173
Country	:	US
Telephone Number	:	877-815-6668
Fax Number	:

Authorized Official
Title or Position	:	ATTENDING PHYSICIAN
Name	:	GERALD LYNZIE COOKE
Credential	:	M.D.
Telephone Number	:	877-815-6668

Provider Enumeration Date	:	05/03/2011
Last Update Date	:	05/03/2011

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