Basic Information
| Provider Information | |||||||||
| NPI: | 1104856780 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENNECKEN | ||||||||
| FirstName: | JOHN FRANCIS | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2490 RIVERSIDE DR | ||||||||
| Address2: | STE B | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786336633 | ||||||||
| FaxNumber: | 4786334295 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 CADMAN PLZ W FL 18 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112013226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9292106135 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35901 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 035901 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 15076501 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 000508934I, J | 05 | GA | MEDICAID |