Healthcare Provider Details

I. General information

NPI: 1962490300
Provider Name (Legal Business Name): DAVID HUBER HENNESSEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 BROAD ST SUITE 422
SEWICKLEY PA
15143-1652
US

IV. Provider business mailing address

701 BROAD ST SUITE 422
SEWICKLEY PA
15143-1652
US

V. Phone/Fax

Practice location:
  • Phone: 412-741-8700
  • Fax: 412-741-3710
Mailing address:
  • Phone: 412-741-8700
  • Fax: 412-741-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD021049E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0632446
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: