MEDICARE: DR. LEO HENIKOFF JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0202X	Pediatric Cardiology Physician	036.039117	IL

General Provider Information

NPI Number	:	1265853170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEO HENIKOFF JR. MD

Provider Business Mailing Address
First Line	:	1437 W LEXINGTON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4013
Country	:	US
Telephone Number	:	312-501-8187
Fax Number	:	312-226-8187

Provider Business Practice Location Address
First Line	:	1437 W LEXINGTON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4013
Country	:	US
Telephone Number	:	312-501-8187
Fax Number	:	312-226-8187

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2013
Last Update Date	:	12/18/2013

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