Provider Demographics
NPI:1235346719
Name:HEPHNER, MICHELLE MARIE (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:HEPHNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6141
Mailing Address - Country:US
Mailing Address - Phone:630-545-3760
Mailing Address - Fax:630-545-3769
Practice Address - Street 1:885 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6141
Practice Address - Country:US
Practice Address - Phone:630-545-3760
Practice Address - Fax:630-545-3769
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL487450OtherMEDICARE GROUP NUMBER
IL0222075OtherBLUE CROSS GROUP ID
IL920780OtherMEDICARE GROUP NUMBER
IL036118939Medicaid
IL3631498336019001OtherCDPG HFS PAYEE ID
ILP00686147OtherMEDICARE RAILROAD
ILCA4748OtherMEDICARE RR GROUP NUMBER
IL3631498336019001OtherCDPG HFS PAYEE ID