Healthcare Provider Details

I. General information

NPI: 1548279649
Provider Name (Legal Business Name): GEORGE HEFNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 N WESTMORELAND RD
LAKE FOREST IL
60045-1659
US

IV. Provider business mailing address

921 SHERWOOD DR
LAKE BLUFF IL
60044-2203
US

V. Phone/Fax

Practice location:
  • Phone: 847-535-6100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number57253
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036083805
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: