Basic Information
| Provider Information | |||||||||
| NPI: | 1083826713 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BURKE MEDICAL GROUP LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 W 203RD STREET | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087487500 | ||||||||
| FaxNumber: | 7087488090 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 W 203RD STREET | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087487500 | ||||||||
| FaxNumber: | 7087488090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 12/29/2009 | ||||||||
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| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | KATHRYN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAN PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7087487500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 042.616914 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036075518 | 05 | IL | MEDICAID |