Healthcare Provider Details

I. General information

NPI: 1336389220
Provider Name (Legal Business Name): W.JAMES HENNEBERG, M.D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2009
Last Update Date: 03/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CONGRESS ST SUITE 400
PASADENA CA
91105-3045
US

IV. Provider business mailing address

10 CONGRESS ST SUITE 400
PASADENA CA
91105-3045
US

V. Phone/Fax

Practice location:
  • Phone: 626-449-6223
  • Fax: 626-449-0035
Mailing address:
  • Phone: 626-449-6223
  • Fax: 626-449-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberG45592
License Number StateCA

VIII. Authorized Official

Name: DR. WILBERT JAMES HENNEBERG
Title or Position: OWNER
Credential: M.D.
Phone: 626-449-6223