Healthcare Provider Details

I. General information

NPI: 1164096962
Provider Name (Legal Business Name): DOUGLAS R HENNEBERG ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E HENRIETTA RD
ROCHESTER NY
14623-5701
US

IV. Provider business mailing address

1000 E HENRIETTA RD
ROCHESTER NY
14623-5701
US

V. Phone/Fax

Practice location:
  • Phone: 585-292-2848
  • Fax:
Mailing address:
  • Phone: 585-292-2848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number001092
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: