Basic Information
| Provider Information | |||||||||
| NPI: | 1144754573 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEINRICH | ||||||||
| FirstName: | KELLI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1704 MAPLE AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602013134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479260106 | ||||||||
| FaxNumber: | 3126942020 | ||||||||
| Practice Location | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082169000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2017 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 036157919 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.