Provider Demographics
NPI:1457439408
Name:HENNIG, BRIAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:HENNIG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S NORTHWEST HWY STE 106
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4262
Mailing Address - Country:US
Mailing Address - Phone:847-470-1500
Mailing Address - Fax:847-470-1550
Practice Address - Street 1:350 S NORTHWEST HWY STE 106
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4262
Practice Address - Country:US
Practice Address - Phone:847-470-1500
Practice Address - Fax:847-470-1550
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001619727OtherBCBS OF ILLINOIS
ILS90453Medicare UPIN
ILK25061Medicare PIN