Basic Information
| Provider Information | |||||||||
| NPI: | 1063411346 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSEL | ||||||||
| FirstName: | XIAOYING | ||||||||
| MiddleName: | GUO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUO | ||||||||
| OtherFirstName: | XIAOYING | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1515 SHERIDAN RD STE 31A | ||||||||
| Address2: | |||||||||
| City: | WILMETTE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600911828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479202200 | ||||||||
| FaxNumber: | 8479202201 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 SHERIDAN RD STE 31A | ||||||||
| Address2: | |||||||||
| City: | WILMETTE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479202200 | ||||||||
| FaxNumber: | 8479202201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036098890 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1627087 | 01 | IL | BLUECROSS/BLUESHIELD | OTHER | 110214961 | 01 | PALMETTO GBA (RAILROADMED | OTHER | 336059176 | 01 | IL | IL SUBSTANCE LICENSE | OTHER | 036098890 | 05 | IL | MEDICAID | 036098890 | 01 | IL | IL STATE LICENSE | OTHER | BG6126761 | 01 | FEDERAL DEA NUMBER | OTHER |