Basic Information
| Provider Information | |||||||||
| NPI: | 1932194016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENNESY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | SHANE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6002 | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618036002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173268630 | ||||||||
| FaxNumber: | 3034264154 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173833140 | ||||||||
| FaxNumber: | 2173834966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 40865 | CO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 67635521 | 05 | CO | MEDICAID | 72507560 | 05 | CO | MEDICAID |