Provider Demographics
NPI:1114014610
Name:HENNESSY, THOMAS N (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:N
Last Name:HENNESSY
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 1:10537 STATE ROAD 54
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-2275
Mailing Address - Country:US
Mailing Address - Phone:727-376-8404
Mailing Address - Fax:727-376-8552
Practice Address - Street 1:10537 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-2275
Practice Address - Country:US
Practice Address - Phone:727-376-8404
Practice Address - Fax:727-376-8552
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36228174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039561700Medicaid
FL565317Medicare UPIN
FL62238Medicare ID - Type Unspecified