Provider Demographics
NPI:1508107061
Name:BURBANK MEDICAL GROUP INC
Entity Type:Organization
Organization Name:BURBANK MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JALAL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHSHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-425-3135
Mailing Address - Street 1:9229 MASSASOIT AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453
Mailing Address - Country:US
Mailing Address - Phone:708-422-2023
Mailing Address - Fax:708-423-2991
Practice Address - Street 1:4817 W 83RD ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60429
Practice Address - Country:US
Practice Address - Phone:708-425-3135
Practice Address - Fax:708-425-6884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088926207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL030088926Medicaid