Healthcare Provider Details

I. General information

NPI: 1013334499
Provider Name (Legal Business Name): JACOB RALPH HENINGER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611
US

IV. Provider business mailing address

2030W CHURCHILL ST
CHICAGO IL
60647-5537
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-5170
  • Fax:
Mailing address:
  • Phone: 563-343-3401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number036.141802
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: