Provider Demographics
NPI:1710974860
Name:HEGGEN, THOMAS A (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:HEGGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1548 STATION PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2719
Mailing Address - Country:US
Mailing Address - Phone:847-850-5882
Mailing Address - Fax:847-850-5892
Practice Address - Street 1:1300 BUSCH PKWY
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-4505
Practice Address - Country:US
Practice Address - Phone:847-850-5882
Practice Address - Fax:845-850-5892
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074991207V00000X, 207R00000X, 2081P2900X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074991Medicaid
IL036074991Medicaid
ILL74837Medicare ID - Type Unspecified