Organization
ELLEN M HENNECKE DOSC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KIM WYLIE (OFFICE MANAGER)
(708) 799-8440
Entity
Organization
Contact information
Practice address
3927 W 95TH ST, EVERGREEN PARK, IL 60805-1903
(708) 799-8440
Mailing address
18141 DIXIE HWY STE 107, HOMEWOOD, IL 60430-2241
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
05/30/2007
Last updated
08/22/2020
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