Provider Demographics
NPI:1114104783
Name:SUBURBAN PRIMARY CARE
Entity Type:Organization
Organization Name:SUBURBAN PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAMDOUH
Authorized Official - Middle Name:LATIF
Authorized Official - Last Name:ISHAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-398-4536
Mailing Address - Street 1:121 S WILKE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-1533
Mailing Address - Country:US
Mailing Address - Phone:847-398-4536
Mailing Address - Fax:847-398-4712
Practice Address - Street 1:121 S WILKE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-1533
Practice Address - Country:US
Practice Address - Phone:847-398-4536
Practice Address - Fax:847-398-4712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-26
Last Update Date:2008-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0042000916207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC41185Medicare UPIN