Provider Demographics
NPI:1437462975
Name:MARLENE K HENZE MD PC
Entity Type:Organization
Organization Name:MARLENE K HENZE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:K
Authorized Official - Last Name:HENZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-416-1331
Mailing Address - Street 1:35 E WILLOW ST STE B
Mailing Address - Street 2:
Mailing Address - City:COAL CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60416-1869
Mailing Address - Country:US
Mailing Address - Phone:815-634-3048
Mailing Address - Fax:815-634-3188
Practice Address - Street 1:151 W HIGH ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1407
Practice Address - Country:US
Practice Address - Phone:815-416-1331
Practice Address - Fax:815-634-3188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-26
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093007261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL080181425OtherMEDICARE RAILROAD
036093007OtherILLINOIS MEDICAID
IL3227787OtherBCBS OF IL
IL3227787OtherBCBS OF IL