Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 036.093294 | IL |
N | 207Q00000X | Family Doctor | 036093294 | IL |
N | 207QS0010X | Family Doctor - Sports Medicine | 036.093294 | IL |
Y | 207R00000X | Internist | 036093294 | IL |
Y | 111NI0900X | Internist | 036093294 | IL |
NPI | 1558462531 |
---|---|
Provider Name | Kurt P Heinking |
First Address | Downers Grove, IL 60515-5430 |
Second Address | Chicago, IL 60673-1265 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2006 |
Last Update Date | 19/09/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
04922838 | BLUE SHIELD PROVIDER # (01) | IL |
080194462 | (02) | IL |
G32145 | (02) | IL |