Provider Demographics
NPI:1780217877
Name:HEDBERG, TREVOR
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:HEDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 EAST HURON STREET
Mailing Address - Street 2:MCGAW PAVILLION, SUITE 1-200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:312-503-1851
Mailing Address - Fax:
Practice Address - Street 1:1525 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5512
Practice Address - Country:US
Practice Address - Phone:773-388-1600
Practice Address - Fax:773-388-8664
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085.008453363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.008453Medicaid