Provider Demographics
NPI:1790891877
Name:BURR RIDGE FAMILY PRACTICE , LTD.
Entity Type:Organization
Organization Name:BURR RIDGE FAMILY PRACTICE , LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARSPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:PORFIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CIUNGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-735-9330
Mailing Address - Street 1:11 SALT CREEK LN STE 125
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-2902
Mailing Address - Country:US
Mailing Address - Phone:630-655-1177
Mailing Address - Fax:
Practice Address - Street 1:11 SALT CREEK LN STE 125
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-2902
Practice Address - Country:US
Practice Address - Phone:630-655-1177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2232216OtherBC/BS OF IL PROVIDER #
IL2232216OtherBC/BS OF IL PROVIDER #
IL2232216OtherBC/BS OF IL PROVIDER #
IL=========Medicaid