Provider Demographics
NPI:1104856780
Name:HENNECKEN, JOHN FRANCIS MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN FRANCIS
Middle Name:MICHAEL
Last Name:HENNECKEN
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 1:2490 RIVERSIDE DR
Mailing Address - Street 2:STE B
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204
Mailing Address - Country:US
Mailing Address - Phone:478-633-6633
Mailing Address - Fax:478-633-4295
Practice Address - Street 1:300 CADMAN PLZ W FL 18
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3226
Practice Address - Country:US
Practice Address - Phone:929-210-6135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA35901207RC0000X
GA035901207RC0000X
NY15076501207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000508934I, JMedicaid
GA511I060277Medicare PIN
E73512Medicare UPIN