Healthcare Provider Details

I. General information

NPI: 1710974860
Provider Name (Legal Business Name): THOMAS A HEGGEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 BUSCH PKWY
BUFFALO GROVE IL
60089-4505
US

IV. Provider business mailing address

1548 STATION PARK DR
GRAYSLAKE IL
60030-2719
US

V. Phone/Fax

Practice location:
  • Phone: 847-850-5882
  • Fax: 845-850-5892
Mailing address:
  • Phone: 847-850-5882
  • Fax: 847-850-5892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036074991
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036074991
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number036074991
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036074991
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: