Provider Demographics
NPI:1790818623
Name:HENNESSEY DERMATOLOGY LLC
Entity Type:Organization
Organization Name:HENNESSEY DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:N PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNESSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-677-5555
Mailing Address - Street 1:161 MADISON AVE RM 6SE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5454
Mailing Address - Country:US
Mailing Address - Phone:212-677-5555
Mailing Address - Fax:212-677-5558
Practice Address - Street 1:161 MADISON AVE RM 6SE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5454
Practice Address - Country:US
Practice Address - Phone:212-677-5555
Practice Address - Fax:212-677-5558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133471174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB12682Medicare UPIN