Provider Demographics
NPI:1013072453
Name:HENNESSY, BRIAN BARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:BARRY
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 1:90 MORGAN ST
Mailing Address - Street 2:STE 202
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5466
Mailing Address - Country:US
Mailing Address - Phone:203-348-2922
Mailing Address - Fax:203-358-8721
Practice Address - Street 1:90 MORGAN ST
Practice Address - Street 2:STE 202
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5466
Practice Address - Country:US
Practice Address - Phone:203-348-2922
Practice Address - Fax:203-358-8721
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025350207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT253500OtherCONNECTICARE
CT010025350CT01OtherBLUE CROSS BLUE SHIELD
CT020139OtherHEALTH NET
CTZP125OtherOXFORD
CT1253509Medicaid
CT1253509Medicaid
CTZP125OtherOXFORD