1891711743 NPI number — KENNETH HEINRICH M.D.

Table of content: KENNETH HEINRICH M.D. (NPI 1891711743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891711743 NPI number — KENNETH HEINRICH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEINRICH
Provider First Name:
KENNETH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891711743
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 REMITT DRIVE
Provider Second Line Business Mailing Address:
LOCKBOX 3274
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60675-3274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-916-5259
Provider Business Mailing Address Fax Number:
231-922-4030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3249 OAK PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERWYN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60402-3429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-783-9100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  38590 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 2009010649 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 036-110486 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207P00000X , with the licence number: 4845120 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 35.093955 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 0101248860 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 46549 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 4301094015 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036110486-5 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036110486-7 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1521933 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01731341 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 036110486 . This is a "BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036110486-8 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891711743 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036110486-3 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891711743 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036110486 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100112540 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036110486-9 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891711743 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036110486-6 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891711743 . This is a "BLUE SHIELD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1891711743 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891711743 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2976472 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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