Provider Demographics
NPI:1528384567
Name:DR. J. WESLEY COOK, D.O., LLC
Entity Type:Organization
Organization Name:DR. J. WESLEY COOK, D.O., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:773-404-1000
Mailing Address - Street 1:2001 W ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6132
Mailing Address - Country:US
Mailing Address - Phone:773-404-1000
Mailing Address - Fax:773-404-9750
Practice Address - Street 1:2001 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6132
Practice Address - Country:US
Practice Address - Phone:773-404-1000
Practice Address - Fax:773-404-9750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36080259207Q00000X
IL336043254207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL725326OtherHUMANA
IL0586501OtherAETNA
IL31604484OtherBCBS OF IL
IL947831Medicare PIN
IL0586501OtherAETNA