Healthcare Provider Details

I. General information

NPI: 1023647831
Provider Name (Legal Business Name): TERAH HENNICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W HARRISON ST STE 400
CHICAGO IL
60612-4861
US

IV. Provider business mailing address

PO BOX 735263
CHICAGO IL
60673-5263
US

V. Phone/Fax

Practice location:
  • Phone: 877-632-6637
  • Fax: 708-409-5179
Mailing address:
  • Phone: 877-632-6637
  • Fax: 708-409-5179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number01096312A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036174905
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number036174905
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number01096312A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: