Healthcare Provider Details

I. General information

NPI: 1104856780
Provider Name (Legal Business Name): JOHN FRANCIS MICHAEL HENNECKEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CADMAN PLZ W FL 18
BROOKLYN NY
11201-3226
US

IV. Provider business mailing address

2490 RIVERSIDE DR STE B
MACON GA
31204
US

V. Phone/Fax

Practice location:
  • Phone: 929-210-6135
  • Fax:
Mailing address:
  • Phone: 478-633-6633
  • Fax: 478-633-4295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35901
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number035901
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number15076501
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: