Provider Demographics
NPI:1144234535
Name:HENNESSEY, PATRICK T (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:T
Last Name:HENNESSEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:STE. 1003
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-6933
Mailing Address - Fax:912-435-5966
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:STE. 1003
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-6933
Practice Address - Fax:912-435-5966
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME63921207R00000X, 207RA0401X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F55103Medicare UPIN