Provider Demographics
NPI:1184737793
Name:HERDEGEN, JAMES J (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:J
Last Name:HERDEGEN
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 1:840 S WOOD ST
Mailing Address - Street 2:806 CSB, MC 719
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-413-9036
Mailing Address - Fax:312-996-4665
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078423207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0021647388OtherBCBS PROVIDER #
IL0001633166OtherBCBS PROVIDER #
IL0040154978OtherBCBS PROVIDER #
IL0081644641OtherBCBS PROVIDER #
IL0081644641OtherBCBS PROVIDER #
IL0021647388OtherBCBS PROVIDER #
IL0040154978OtherBCBS PROVIDER #