Provider Demographics
NPI:1982805164
Name:ILLUM, HENRIK B (MD)
Entity type:Individual
Prefix:DR
First Name:HENRIK
Middle Name:B
Last Name:ILLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-2987
Practice Address - Street 1:1615 HOSPITAL PARKWAY
Practice Address - Street 2:SUITE 300
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022
Practice Address - Country:US
Practice Address - Phone:817-354-5581
Practice Address - Fax:817-359-9062
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2015-06-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXN0118207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194728503Medicaid
TXP01449276OtherRAILROAD MEDICARE
TX343621YTU3Medicare PIN