Provider Demographics
NPI:1558462531
Name:HEINKING, KURT P (DO)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:P
Last Name:HEINKING
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 1:3450 LACEY RD
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5430
Mailing Address - Country:US
Mailing Address - Phone:630-743-4500
Mailing Address - Fax:
Practice Address - Street 1:26520 NETWORK PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60673-1265
Practice Address - Country:US
Practice Address - Phone:630-743-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093294207R00000X, 207Q00000X
IL036.093294207QS0010X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04922838OtherBLUE SHIELD PROVIDER #
IL080194462Medicare UPIN
ILG32145Medicare UPIN
ILK25434Medicare PIN