Provider Demographics
NPI:1992849137
Name:HEFELE, KIRSTEN G (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:G
Last Name:HEFELE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KIRSTEN
Other - Middle Name:G
Other - Last Name:HEFELE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2740 W FOSTER AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3547
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-293-4197
Practice Address - Street 1:2800 N SHERIDAN RD STE 309
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6160
Practice Address - Country:US
Practice Address - Phone:773-248-6913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104387207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK52343OtherMEDICARE INDIVIDUAL PTAN
IL110248408OtherMEDICARE RAILROAD EMPLOYER PTAN
IL1447266176OtherMEDICARE GROUP NPI
IL036104387Medicaid
IL745950OtherMEDICARE GROUP PTAN
IL1992849137OtherMEDICARE INDIVIDUAL NPI