HEINRICH, KENNETH (MD)

Provider Demographics

• NPI: 1891711743
• Name: HEINRICH, KENNETH (MD)
• Entity Type: Individual
• First Name: KENNETH
• Last Name: HEINRICH
• Gender: M
• Credentials: MD
• Mailing Address - Street 1: 75 REMITT DRIVE
• Mailing Address - Street 2: LOCKBOX 3274
• Mailing Address - City: CHICAGO
• Mailing Address - State: IL
• Mailing Address - Zip Code: 60675-3274
• Mailing Address - Country: US
• Mailing Address - Phone: 866-916-5259
• Mailing Address - Fax: 231-922-4030
• Practice Address - Street 1: 3249 OAK PARK AVE
• Practice Address - City: BERWYN
• Practice Address - State: IL
• Practice Address - Zip Code: 60402-3429
• Practice Address - Country: US
• Practice Address - Phone: 708-783-9100
• Is Sole Proprietor?: No
• Enumeration Date: 2006-07-14
• Last Update Date: 2017-02-06

Provider Licenses

State	License ID	Taxonomies
IA	38590	207P00000X
MO	2009010649	207P00000X
IL	036-110486	207P00000X
WI	4845120	207P00000X
OH	35.093955	207P00000X
VA	0101248860	207P00000X
TN	46549	207P00000X
MI	4301094015	207P00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	207P00000X	Allopathic & Osteopathic Physicians	Emergency Medicine

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IL	036110486-5	Medicaid
IL	036110486-7	Medicaid
TN	1521933	Medicaid
VA	P01731341	Other	RAILROAD MEDICARE
IL	036110486	Other	BLUE SHIELD
IL	036110486-8	Medicaid
MI	1891711743	Medicaid
IL	036110486-3	Medicaid
IA	1891711743	Medicaid
IL	036110486	Medicaid
KY	7100112540	Medicaid
IL	036110486-9	Medicaid
VA	1891711743	Medicaid
IL	036110486-6	Medicaid
IA	1891711743	Other	BLUE SHIELD
WI	1891711743	Medicaid
MO	1891711743	Medicaid
OH	2976472	Medicaid
OH	HE4269782	Medicare PIN
TN	103I939037	Medicare PIN
IL	036110486-5	Medicaid
IL	036110486	Medicaid
IL	036110486-7	Medicaid
IL	036110486-9	Medicaid
MI	1891711743	Medicaid
VA	VV1966B	Medicare PIN
IL	IL1943005	Medicare PIN
WI	018050022	Medicare PIN
	I09410	Medicare UPIN
IL	036110486-8	Medicaid
OH	2976472	Medicaid
IA	1891711743	Medicaid
OH	HE4269781	Medicare PIN
MI	MI1609036	Medicare PIN
IA	IB1436007	Medicare PIN
IL	567730013	Medicare PIN