Provider Demographics
NPI:1760820930
Name:HENIEN, SHADY (MD)
Entity Type:Individual
Prefix:DR
First Name:SHADY
Middle Name:
Last Name:HENIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 E REDSTONE AVE
Mailing Address - Street 2:STE A
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5350
Mailing Address - Country:US
Mailing Address - Phone:217-492-9115
Mailing Address - Fax:217-522-1206
Practice Address - Street 1:800 E CARPENTER ST # 62
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-1000
Practice Address - Country:US
Practice Address - Phone:217-492-9115
Practice Address - Fax:217-522-1206
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD15478207RC0000X
IL036151656207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease