Basic Information
| Provider Information | |||||||||
| NPI: | 1154326759 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRICHS | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6002 | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618036002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173268630 | ||||||||
| FaxNumber: | 2173792604 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 W. ANTHONY DRIVE | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618017431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173262255 | ||||||||
| FaxNumber: | 2173260210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 05/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 03611190 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036111690 | 05 | IL | MEDICAID |