Provider Demographics
NPI:1598006546
Name:ENDOCRINE DIABETES CLINIC LTD
Entity Type:Organization
Organization Name:ENDOCRINE DIABETES CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDALLAH
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTARSHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-479-6522
Mailing Address - Street 1:3830 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2004
Mailing Address - Country:US
Mailing Address - Phone:708-479-6522
Mailing Address - Fax:
Practice Address - Street 1:3830 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2004
Practice Address - Country:US
Practice Address - Phone:708-479-6522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093254207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093254Medicaid