MEDICARE: DEREK HENNIG OD

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	152W00000X	Optometrist	046011094	IL

General Provider Information

NPI Number	:	1215466008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK HENNIG OD

Provider Business Mailing Address
First Line	:	1700 18TH ST
Second Line	:
City	:	CHARLESTON
State	:	IL
Zip	:	61920-3607
Country	:	US
Telephone Number	:	217-345-6600
Fax Number	:	217-345-6622

Provider Business Practice Location Address
First Line	:	1700 18TH ST
Second Line	:
City	:	CHARLESTON
State	:	IL
Zip	:	61920-3607
Country	:	US
Telephone Number	:	217-345-6600
Fax Number	:	217-345-6622

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

Provider Enumeration Date	:	06/06/2017
Last Update Date	:	06/06/2017

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