Provider Demographics
NPI:1528045119
Name:HENNESSY, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
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 1:1208 MORGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026
Mailing Address - Country:US
Mailing Address - Phone:302-545-8201
Mailing Address - Fax:
Practice Address - Street 1:3411 SILVERSIDE RD
Practice Address - Street 2:WEBSTER BUILDING, SUITE 103
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810
Practice Address - Country:US
Practice Address - Phone:302-479-8464
Practice Address - Fax:302-479-8463
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005039207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE003294I23Medicare PIN