Cook County
Organization Active NPI Primary Care Clinic/Center · Cicero, IL
NPI 1104946904 · NPPES record last updated Feb 22, 2019
Key facts
- NPI
- 1104946904
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Primary Care Clinic/Center 261QP2300X
- License
- 0005272 (IL)
- Legal business name
- COOK COUNTY
- Practice address
- 2423 S Austin Blvd
Cicero, IL 60804-2616 - Phone
- (708) 656-1130
- NPI assigned
- Mar 29, 2007
- Organization subpart
- Yes
- Parent organization (as reported)
- COOK COUNTY
Authorized official
- Name
- Scott Andrle
- Title
- Director of Managed Care Operations
- Phone
- (312) 864-4649
Other NPIs on the same Medicare enrollment 29
Practitioners 2
-
Fred Rosen, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031209000747 | IL | Part B Supplier - Clinic/Group Practice | 2860398088 |
Receives reassigned benefits from 1,783 practitioners 29 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Chicago, IL; Ford Heights, IL; North Riverside, IL; Robbins, IL; Arlington Heights, IL |
National Provider Directory
- Part of
- Community Triage Center
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Primary Care Clinic/Center | 261QP2300X | 0005272 | IL | Yes |
Addresses
Primary practice location
2423 S Austin Blvd
Cicero, IL 60804-2616
Mailing address
1900 W Polk St RM 220C
Chicago, IL 60612-3723
Phone (312) 864-4649
Other names
- MORTON EAST ADOLESCENT HEALTH CENTER
Other providers in Cicero, IL
- Xiomara D. Clanton
- Gary J. Clyman
- Larry Coats
- Concentra Health Serivces, Inc.
- Diana Contreras
- Cook County
- Muneera Crystal Cooper
- Sherita Cooper
- Diana Cosajay
- Katelynn Craft
All providers in Cicero, IL · Primary Care Clinic/Center in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 22, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.