Provider Demographics
NPI:1215169065
Name:BURRUSSI, TAMIKA (DN)
Entity type:Individual
Prefix:
First Name:TAMIKA
Middle Name:
Last Name:BURRUSSI
Suffix:
Gender:F
Credentials:DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0187
Mailing Address - Country:US
Mailing Address - Phone:708-479-6522
Mailing Address - Fax:708-479-6597
Practice Address - Street 1:356 W SUPERIOR ST FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3416
Practice Address - Country:US
Practice Address - Phone:312-932-0300
Practice Address - Fax:312-932-0304
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL181.000359174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL181.000359Medicaid