Provider Demographics
NPI:1487664561
Name:COOK COUNTY
Entity Type:Organization
Organization Name:COOK COUNTY
Other - Org Name:PROVIDENT HOSPITAL OF COOK COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-864-4649
Mailing Address - Street 1:500 EAST 51ST STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-2494
Mailing Address - Country:US
Mailing Address - Phone:312-572-1200
Mailing Address - Fax:312-572-1294
Practice Address - Street 1:500 EAST 51ST STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-2494
Practice Address - Country:US
Practice Address - Phone:312-572-1200
Practice Address - Fax:312-572-1294
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOK COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-09
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0004549282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL93OtherBLUE CROSS BLUE SHIELD
IL93OtherBLUE CROSS BLUE SHIELD