MEDICARE: DR. RUSSELL B HENNESSEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	022466	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497793236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL B HENNESSEY

Provider Business Mailing Address
First Line	:	3025 OLD MOORINGSPORT RD
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71107-4022
Country	:	US
Telephone Number	:	318-797-1743
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 S SPRUCE ST
Second Line	:
City	:	VIVIAN
State	:	LA
Zip	:	71082-3232
Country	:	US
Telephone Number	:	318-375-3239
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	07/08/2007

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