Provider Demographics
NPI:1477661254
Name:HENNIE, THOMAS ALLAN (DPM ND)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALLAN
Last Name:HENNIE
Suffix:
Gender:M
Credentials:DPM ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29001 CEDAR RD
Mailing Address - Street 2:STE 500
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124
Mailing Address - Country:US
Mailing Address - Phone:440-461-4242
Mailing Address - Fax:
Practice Address - Street 1:29001 CEDAR RD
Practice Address - Street 2:STE 500
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124
Practice Address - Country:US
Practice Address - Phone:440-461-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1726213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0283527Medicaid
T80409Medicare UPIN
OH0283527Medicaid