Basic Information
| Provider Information | |||||||||
| NPI: | 1942234430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOKE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 WINFIELD ROAD | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309334700 | ||||||||
| FaxNumber: | 6309334721 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 WINFIELD ROAD | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309334700 | ||||||||
| FaxNumber: | 6309334721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 05/24/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036055493 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208M00000X | 036055493 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 3631498336019001 | 01 | IL | CDPG HFS PAYEE ID | OTHER | 0222075 | 01 | IL | BLUE CROSS GROUP NUMBER | OTHER | 036055493 | 05 | IL | MEDICAID | 363149833 | 01 | IL | TAX IDENTIFICATION NUMBER | OTHER |