Provider Demographics
NPI:1972767895
Name:HERATY, STEPHANIE ANN (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ANN
Last Name:HERATY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:HERATY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2801 LAKESIDE DR STE 209
Mailing Address - Street 2:
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1271
Mailing Address - Country:US
Mailing Address - Phone:847-562-1410
Mailing Address - Fax:847-562-0830
Practice Address - Street 1:1000 CENTRAL ST STE 700
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1769
Practice Address - Country:US
Practice Address - Phone:847-869-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.119864207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology