Basic Information
Provider Information | |||||||||
NPI: | 1063459386 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENNESSEY | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | V | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 330 BROOKLINE AVE. | ||||||||
Address2: | BETH ISRAEL DEACONESS MEDICAL CENTER | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 022151358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 330 BROOKLINE AVE. | ||||||||
Address2: | BETH ISRAEL DEACONESS MEDICAL CENTER | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 022154141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6176679344 | ||||||||
FaxNumber: | 6176677060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2006 | ||||||||
LastUpdateDate: | 02/17/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 230618 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | MD08376 | RI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | 9006723 | 05 | RI |   | MEDICAID |