Provider Demographics
NPI:1700864725
Name:BULMASH, JACK M (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:M
Last Name:BULMASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 S. 5TH AVE.
Mailing Address - Street 2:BLD.1 HINES VA HOSPITAL
Mailing Address - City:HINES
Mailing Address - State:IL
Mailing Address - Zip Code:60141-3030
Mailing Address - Country:US
Mailing Address - Phone:708-202-5636
Mailing Address - Fax:
Practice Address - Street 1:5000 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-5636
Practice Address - Fax:312-951-1488
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03644313207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036044313Medicaid
ILC42506Medicare UPIN
IL036044313Medicaid