Healthcare Provider Details

I. General information

NPI: 1841586799
Provider Name (Legal Business Name): MARY ELEANOR HEGSTROM D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

IV. Provider business mailing address

5359 W FULLERTON AVE
CHICAGO IL
60639-1450
US

V. Phone/Fax

Practice location:
  • Phone: 872-588-3000
  • Fax: 872-588-3001
Mailing address:
  • Phone: 773-836-2785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036134967
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125060221
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: