Basic Information
| Provider Information | |||||||||
| NPI: | 1962490300 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENNESSEY | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | HUBER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 BROAD ST | ||||||||
| Address2: | SUITE 422 | ||||||||
| City: | SEWICKLEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151431652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4127418700 | ||||||||
| FaxNumber: | 4127413710 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 BROAD ST | ||||||||
| Address2: | SUITE 422 | ||||||||
| City: | SEWICKLEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151431652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4127418700 | ||||||||
| FaxNumber: | 4127413710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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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 | 208000000X | MD021049E | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0632446 | 05 | PA | MEDICAID |