Provider Demographics
NPI:1700058898
Name:BURBANK MEDICAL CENTER SC
Entity Type:Organization
Organization Name:BURBANK MEDICAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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 1:4817 W 83RD ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459-2790
Mailing Address - Country:US
Mailing Address - Phone:708-425-3135
Mailing Address - Fax:708-425-6884
Practice Address - Street 1:4817 W 83RD ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-2790
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:2008-03-28
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088926207R00000X
IL036054337207V00000X
IL016002638213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088926Medicaid
IL01639156OtherBLUE CROSS
IL216342Medicare PIN
ILK50364Medicare PIN
IL01639156OtherBLUE CROSS