1649551938 NPI number — COOK COUNTY

Table of content: (NPI 1649551938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649551938 NPI number — COOK COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COOK COUNTY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OAK FOREST URGENT/IMMEDIATE CARE CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649551938
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 W POLK ST STE 220C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60612-3723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-864-4649
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15900 CICERO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK FOREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-864-4779
Provider Business Practice Location Address Fax Number:
312-864-9877
Provider Enumeration Date:
08/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ANDRLE
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF MANAGED CARE OPERATIONS
Authorized Official Telephone Number:
312-864-4649

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  0005272 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X , with the licence number: 0005272 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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