Provider Demographics
NPI:1437649795
Name:HANEWICH, MATTHEW CHRISTOPHER (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:CHRISTOPHER
Last Name:HANEWICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10837 S CICERO AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-6458
Mailing Address - Country:US
Mailing Address - Phone:708-636-7575
Mailing Address - Fax:708-636-6193
Practice Address - Street 1:4440 W 95TH ST STE 1126M
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2600
Practice Address - Country:US
Practice Address - Phone:708-684-5405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-12
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.169242207RC0000X
IADO-05803208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVSL1336OtherNEVADA STATE BOARD OF OSTEOPATHIC MEDICINE