Provider Demographics
NPI:1912994393
Name:HENNESSEY, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:HENNESSEY
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 1:7638 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-4157
Mailing Address - Country:US
Mailing Address - Phone:708-452-4257
Mailing Address - Fax:708-452-4283
Practice Address - Street 1:7638 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-4157
Practice Address - Country:US
Practice Address - Phone:708-452-4257
Practice Address - Fax:708-452-4283
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090346207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG13893Medicare UPIN