Provider Demographics
NPI:1154548121
Name:KIDANU BIRHANU MD SC
Entity type:Organization
Organization Name:KIDANU BIRHANU MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KIDANU
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRHANU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-229-1395
Mailing Address - Street 1:5660 W 95TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2380
Mailing Address - Country:US
Mailing Address - Phone:708-229-1395
Mailing Address - Fax:708-857-4420
Practice Address - Street 1:5660 W 95TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2380
Practice Address - Country:US
Practice Address - Phone:708-229-1395
Practice Address - Fax:708-857-4420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072060207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01633358OtherBCBS OF IL
IL110248456OtherRAILROAD MEDICARE
IL205043Medicare ID - Type Unspecified