Basic Information
| Provider Information | |||||||||
| NPI: | 1346394715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BALUCHI MEDICAL GROUP LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 S. 161 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK TERRACE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309328000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1S161 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | OAKBROOK TERRACE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601813904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309328000 | ||||||||
| FaxNumber: | 6309328025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 10/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | AMJAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6309328000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 21606805 | 01 | IL | BCBS PROVIDER ID | OTHER | CJ5711 | 01 | IL | RAILROAD MEDICARE | OTHER |