Provider Demographics
NPI:1659616142
Name:CHICAGO WOMENS HEALTH PRACTITIONER, LLC
Entity Type:Organization
Organization Name:CHICAGO WOMENS HEALTH PRACTITIONER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:COTHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-203-2249
Mailing Address - Street 1:110 E DELAWARE PL
Mailing Address - Street 2:SUITE 1703
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1481
Mailing Address - Country:US
Mailing Address - Phone:708-468-4070
Mailing Address - Fax:
Practice Address - Street 1:45 W 111TH ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4200
Practice Address - Country:US
Practice Address - Phone:708-468-4070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-10
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36.091412207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213903347-60611-30Medicaid
IL213903347-60611-30Medicaid