Provider Demographics
NPI:1417001108
Name:HERNAEZ, EDWARD E (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:E
Last Name:HERNAEZ
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 1:7124 W TOUHY AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-4526
Mailing Address - Country:US
Mailing Address - Phone:847-983-8695
Mailing Address - Fax:847-972-1926
Practice Address - Street 1:7124 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-4526
Practice Address - Country:US
Practice Address - Phone:847-983-8695
Practice Address - Fax:847-972-1926
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036 093 705207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093705Medicaid
ILG34901Medicare UPIN