Basic Information
Provider Information | |||||||||
NPI: | 1508952011 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COOK | ||||||||
FirstName: | EDWIN | ||||||||
MiddleName: | JOHN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | COOK | ||||||||
OtherFirstName: | EDWIN | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | D.O. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 4001 VOLLMER RD | ||||||||
Address2: |   | ||||||||
City: | OLYMPIA FIELDS | ||||||||
State: | IL | ||||||||
PostalCode: | 604613168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7084818883 | ||||||||
FaxNumber: | 7086795354 | ||||||||
Practice Location | |||||||||
Address1: | 4001 VOLLMER RD. | ||||||||
Address2: |   | ||||||||
City: | OLYMPIA FIELDS | ||||||||
State: | IL | ||||||||
PostalCode: | 60461 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7084818883 | ||||||||
FaxNumber: | 7084812917 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 07/22/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 036054673 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 036054673 | 05 | IL |   | MEDICAID |