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General NPI Number Information
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NPI Number | 1114956216
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Entity Type | Individual
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Provider Name | ROY RANDEL HENNEBERG MD
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Gender | Male
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Dates
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Enumeration Date | 07/01/2006
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Last Update Date | 05/14/2020
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Provider Practice Location Address
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Address Line | 980 W IRONWOOD DR SUITE 304
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City | COEUR D ALENE
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State | ID
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Zip | 83814
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Country | US
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Telephone | 208-765-4888
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Fax | 208-667-8618
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Provider Business Mailing Address
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Address Line | 980 W IRONWOOD DR STE 201
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2668
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Country | US
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Telephone | 208-765-4888
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Fax | 208-667-8618
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | M4722
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License Number State | ID
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