Healthcare Provider Details

I. General information

NPI: 1730125428
Provider Name (Legal Business Name): TIMOTHY D HENNE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2373 64TH ST SW STE 2700
BYRON CENTER MI
49315-7978
US

IV. Provider business mailing address

1111 LEFFINGWELL AVE NE
GRAND RAPIDS MI
49525-6406
US

V. Phone/Fax

Practice location:
  • Phone: 616-465-5910
  • Fax: 616-465-5911
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number4301072748
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: