Provider Demographics
NPI:1336389220
Name:W.JAMES HENNEBERG, M.D. INC.
Entity Type:Organization
Organization Name:W.JAMES HENNEBERG, M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HENNEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-449-6223
Mailing Address - Street 1:10 CONGRESS ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3045
Mailing Address - Country:US
Mailing Address - Phone:626-449-6223
Mailing Address - Fax:626-449-0035
Practice Address - Street 1:10 CONGRESS ST
Practice Address - Street 2:SUITE 400
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3045
Practice Address - Country:US
Practice Address - Phone:626-449-6223
Practice Address - Fax:626-449-0035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-04
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45592207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA50104Medicare UPIN
CAG45592Medicare PIN