Provider Demographics
NPI:1114238680
Name:BURKE, ELAINE FELICIA (DO)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:FELICIA
Last Name:BURKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:FELICIA
Other - Last Name:GOULD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 527
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-0527
Mailing Address - Country:US
Mailing Address - Phone:312-878-4521
Mailing Address - Fax:
Practice Address - Street 1:4740 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4689
Practice Address - Country:US
Practice Address - Phone:773-769-0205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT518272084P0800X
WI68608-212084P0800X
IL036.1448452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-144845OtherILLINOIS STATE LICENSE
WI68608-21OtherWISCONSIN STATE LICENSE