Provider Demographics
NPI:1649390022
Name:COOK COUNTY
Entity Type:Organization
Organization Name:COOK COUNTY
Other - Org Name:COOK COUNTY HEALTH AT BLUE ISLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE
Authorized Official - Prefix:
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 1:12757 SOUTH WESTERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406
Mailing Address - Country:US
Mailing Address - Phone:312-864-4665
Mailing Address - Fax:
Practice Address - Street 1:12757 SOUTH WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406
Practice Address - Country:US
Practice Address - Phone:708-633-2555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOK COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-30
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001743261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========049Medicaid