Healthcare Provider Details

I. General information

NPI: 1033520226
Provider Name (Legal Business Name): SHANE PATRICK HENNESSY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2014
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PLAZA DR STE 400
BELLE VERNON PA
15012
US

IV. Provider business mailing address

800 PLAZA DR SUITE 400
BELLE VERNON PA
15012-4019
US

V. Phone/Fax

Practice location:
  • Phone: 724-379-5816
  • Fax: 724-379-5813
Mailing address:
  • Phone: 724-379-5816
  • Fax: 724-379-5874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS018852
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: