Basic Information
| Provider Information | |||||||||
| NPI: | 1992849137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEFELE | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEFELE | ||||||||
| OtherFirstName: | KIRSTEN | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2740 W FOSTER AVE | ||||||||
| Address2: | STE 310 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738788200 | ||||||||
| FaxNumber: | 7732934197 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 N SHERIDAN RD STE 309 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606576160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732486913 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036104387 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | K52343 | 01 | IL | MEDICARE INDIVIDUAL PTAN | OTHER | 110248408 | 01 | IL | MEDICARE RAILROAD EMPLOYER PTAN | OTHER | 1447266176 | 01 | IL | MEDICARE GROUP NPI | OTHER | 036104387 | 05 | IL | MEDICAID | 745950 | 01 | IL | MEDICARE GROUP PTAN | OTHER | 1992849137 | 01 | IL | MEDICARE INDIVIDUAL NPI | OTHER |