Healthcare Provider Details

I. General information

NPI: 1528898038
Provider Name (Legal Business Name): JOHN CHARLES HENNESSEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PHALEN BLVD HEALTHPARTNERS SPECIALTY CENTER - VASCULAR SURGERY 4TH
SAINT PAUL MN
55130-5302
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-967-7977
  • Fax: 651-254-7969
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number333269
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number85238-20
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number78317
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: