Provider Demographics
NPI:1114956216
Name:HENNEBERG, ROY RANDEL (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:RANDEL
Last Name:HENNEBERG
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 1:980 W IRONWOOD DR STE 201
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2668
Mailing Address - Country:US
Mailing Address - Phone:208-765-4888
Mailing Address - Fax:208-667-8618
Practice Address - Street 1:980 W IRONWOOD DR
Practice Address - Street 2:SUITE 304
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-765-4888
Practice Address - Fax:208-667-8618
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4722174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001684500Medicaid