MEDICARE: KURT P HEINKING D.O.

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	036093294	IL
2	207Q00000X	Family Medicine Physician	036093294	IL
3	207QS0010X	Sports Medicine (Family Medicine) Physician	036.093294	IL
4	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	036.093294	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04922838	OTHER	IL	BLUE SHIELD PROVIDER #

General Provider Information

NPI Number	:	1558462531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KURT P HEINKING D.O.

Provider Business Mailing Address
First Line	:	3450 LACEY RD
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-5430
Country	:	US
Telephone Number	:	630-743-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	26520 NETWORK PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-1265
Country	:	US
Telephone Number	:	630-743-4500
Fax Number	:

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

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	09/19/2013

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Directions to “ KURT P HEINKING D.O.” Practice Location

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