MEDICARE: ROLANDO HENRIQUEZ M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	036087152	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2205538	OTHER	IL	BCBS OF ILLINOIS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	363950044	OTHER	IL	TAX ID

General Provider Information

NPI Number	:	1144370990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROLANDO HENRIQUEZ M.D.

Provider Business Mailing Address
First Line	:	229 W GRAND AVENUE
Second Line	:	SUITE R
City	:	BENSENVILLE
State	:	IL
Zip	:	60106
Country	:	US
Telephone Number	:	630-238-9235
Fax Number	:	630-238-0426

Provider Business Practice Location Address
First Line	:	1841 W ARMY TRAIL RD
Second Line	:
City	:	ADDISON
State	:	IL
Zip	:	60101-1901
Country	:	US
Telephone Number	:	630-238-9235
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	05/04/2012

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