Provider Demographics
NPI:1154326759
Name:HENRICHS, JEREMY W (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:W
Last Name:HENRICHS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6002
Mailing Address - Country:US
Mailing Address - Phone:217-326-8630
Mailing Address - Fax:217-379-2604
Practice Address - Street 1:810 W. ANTHONY DRIVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-7431
Practice Address - Country:US
Practice Address - Phone:217-326-2255
Practice Address - Fax:217-326-0210
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03611190207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111690Medicaid
ILK11619Medicare ID - Type Unspecified
ILH42573Medicare UPIN