Healthcare Provider Details

I. General information

NPI: 1780217877
Provider Name (Legal Business Name): TREVOR HEDBERG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 2030
CHICAGO IL
60611-2830
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 2030
CHICAGO IL
60611-2830
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-6831
  • Fax: 312-926-2200
Mailing address:
  • Phone: 312-926-6831
  • Fax: 312-926-2200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.008453
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: