Healthcare Provider Details

I. General information

NPI: 1518346170
Provider Name (Legal Business Name): 83RD PROFESSIONAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6723 KINGREY HIGHWAY
WILLOWBROOK IL
60527
US

IV. Provider business mailing address

6723 KINGREY HIGHWAY
WILLOWBROOK IL
60527
US

V. Phone/Fax

Practice location:
  • Phone: 630-850-0600
  • Fax: 630-850-0608
Mailing address:
  • Phone: 630-850-0600
  • Fax: 630-850-0608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: TALAT GHAUS
Title or Position: OWNER/ MANAGER
Credential: MD
Phone: 630-234-4895