Provider Demographics
NPI:1407262314
Name:BURKE, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:BURKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5319 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WONDER LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60097-8726
Mailing Address - Country:US
Mailing Address - Phone:312-719-0987
Mailing Address - Fax:
Practice Address - Street 1:929 W FOSTER AVE
Practice Address - Street 2:STE. 3002
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1491
Practice Address - Country:US
Practice Address - Phone:312-719-0987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0380343702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry