MEDICARE: ELLEN M HENNECKE DOSC

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01628066	OTHER	IL	BLUE SHIELD

General Provider Information

NPI Number	:	1780885657
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLEN M HENNECKE DOSC

Provider Business Mailing Address
First Line	:	18141 DIXIE HWY STE 107
Second Line	:
City	:	HOMEWOOD
State	:	IL
Zip	:	60430-2241
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3927 W 95TH ST
Second Line	:
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-1903
Country	:	US
Telephone Number	:	708-799-8440
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KIM WYLIE
Credential	:
Telephone Number	:	708-799-8440

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	08/22/2020

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