Provider Demographics
NPI:1689603847
Name:HENNEBERG, ANDREW ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:ANTHONY
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
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
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 201
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
IDM-9485174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807438700Medicaid