Healthcare Provider Details

I. General information

NPI: 1700058898
Provider Name (Legal Business Name): BURBANK MEDICAL CENTER SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4817 W 83RD ST
BURBANK IL
60459-2790
US

IV. Provider business mailing address

4817 W 83RD ST
BURBANK IL
60459-2790
US

V. Phone/Fax

Practice location:
  • Phone: 708-425-3135
  • Fax: 708-425-6884
Mailing address:
  • Phone: 708-425-3135
  • Fax: 708-425-6884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036088926
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036054337
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016002638
License Number StateIL

VIII. Authorized Official

Name: JALAL DAHSHE
Title or Position: PRESIDENT
Credential: MD
Phone: 708-425-3135