Basic Information
| Provider Information | |||||||||
| NPI: | 1235384298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOKE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 N WINFIELD RD | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601901295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309334700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 N WINFIELD RD | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601901295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309334700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2008 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N2450 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 036127781 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RP1001X | 036127781 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 036127781 | 01 | IL | MEDICAID | OTHER | F400201360 | 01 | IL | MEDICARE PTAN (INDIVIDUAL) | OTHER | 206147 | 01 | IL | MEDICARE PTAN (GROUP) | OTHER |