Provider Demographics
NPI:1063459386
Name:HENNESSEY, JAMES V (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:V
Last Name:HENNESSEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BROOKLINE AVE.
Mailing Address - Street 2:BETH ISRAEL DEACONESS MEDICAL CENTER
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE.
Practice Address - Street 2:BETH ISRAEL DEACONESS MEDICAL CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-4141
Practice Address - Country:US
Practice Address - Phone:617-667-9344
Practice Address - Fax:617-667-7060
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA230618207RE0101X
RIMD08376207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9006723Medicaid
A17566Medicare UPIN
007056365Medicare ID - Type Unspecified