Provider Demographics
NPI:1730280744
Name:COEUR OBSTETRICS AND GYNECOLOGY, PLLC
Entity Type:Organization
Organization Name:COEUR OBSTETRICS AND GYNECOLOGY, PLLC
Other - Org Name:D. ANTHONY & R. RANDEL HENNEBERG, PTR'S
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:HENNEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-765-4888
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 STE 201
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2668
Practice Address - Country:US
Practice Address - Phone:208-765-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9485174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I59182Medicare UPIN
IDB6352Medicare UPIN
IDS79304Medicare UPIN
ID1114502Medicare ID - Type Unspecified
ID1342291Medicare ID - Type Unspecified
ID807438700Medicaid
ID0002588900Medicaid
IDA92436Medicare UPIN
ID002588900Medicaid
ID805337200Medicaid
ID001684500Medicaid