Healthcare Provider Details

I. General information

NPI: 1114238680
Provider Name (Legal Business Name): ELAINE FELICIA BURKE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELAINE FELICIA GOULD D.O.

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 N CLARK ST
CHICAGO IL
60640-4689
US

IV. Provider business mailing address

PO BOX 527
MILFORD CT
06460-0527
US

V. Phone/Fax

Practice location:
  • Phone: 773-769-0205
  • Fax:
Mailing address:
  • Phone: 312-878-4521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number51827
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number68608-21
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.144845
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: