MEDICARE: DR. CHARMAINE M HENNES M.D

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	207Q00000X	Family Medicine Physician	036-116385	IL

General Provider Information

NPI Number	:	1407075856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARMAINE M HENNES M.D

Provider Business Mailing Address
First Line	:	4653 N PLAINFIELD AVE
Second Line	:
City	:	NORRIDGE
State	:	IL
Zip	:	60706-4336
Country	:	US
Telephone Number	:	708-452-7449
Fax Number	:

Provider Business Practice Location Address
First Line	:	6322 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-4422
Country	:	US
Telephone Number	:	773-736-8088
Fax Number	:

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

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/08/2007

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