Provider Demographics
NPI:1609862382
Name:HEFFERNAN, EILEEN E (MD)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:E
Last Name:HEFFERNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 N HAMMES AVE UNIT D
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8136
Mailing Address - Country:US
Mailing Address - Phone:815-744-4357
Mailing Address - Fax:815-744-6022
Practice Address - Street 1:202 N HAMMES AVE UNIT D
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8136
Practice Address - Country:US
Practice Address - Phone:815-744-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081868207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081868Medicaid
ILE90155Medicare UPIN