MEDICARE: MICHAEL HENNESSEY M. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	ME83428	FL

General Provider Information

NPI Number	:	1457315277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL HENNESSEY M. D.

Provider Business Mailing Address
First Line	:	907 MAR WALT DR
Second Line	:	SUITE 2024
City	:	FT WALTON BEACH
State	:	FL
Zip	:	32547-6960
Country	:	US
Telephone Number	:	850-243-2229
Fax Number	:	850-862-0124

Provider Business Practice Location Address
First Line	:	907 MAR WALT DR
Second Line	:	SUITE 2024
City	:	FT WALTON BEACH
State	:	FL
Zip	:	32547-6960
Country	:	US
Telephone Number	:	850-243-2229
Fax Number	:	850-862-0124

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	08/15/2011

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