Individual
ELLEN M HENNECKE
Active
Sole proprietor
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
3927 W 95TH ST, EVERGREEN PARK, IL 60805-1903
(708) 952-4566
(708) 952-4568
Mailing address
18141 DIXIE HWY, STE 107, HOMEWOOD, IL 60430-2238
(708) 799-8440
(708) 799-8446
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01628066
BLUE SHIELD
IL
Enumeration date
12/16/2005
Last updated
07/08/2007
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