Provider Demographics
NPI:1841586799
Name:HEGSTROM, MARY ELEANOR (DO)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELEANOR
Last Name:HEGSTROM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5359 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1450
Mailing Address - Country:US
Mailing Address - Phone:773-836-2785
Mailing Address - Fax:
Practice Address - Street 1:3860 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2460
Practice Address - Country:US
Practice Address - Phone:872-588-3000
Practice Address - Fax:872-588-3001
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036134967207Q00000X
IL125060221207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine