Basic Information
| Provider Information | |||||||||
| NPI: | 1164441069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENNELLY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500-6335 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191780001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158078000 | ||||||||
| FaxNumber: | 2158078235 | ||||||||
| Practice Location | |||||||||
| Address1: | 3998 RED LION RD | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191141436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156124000 | ||||||||
| FaxNumber: | 2158078235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OS010405L | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0019010010001 | 05 | PA | MEDICAID | 1027108 | 01 | PA | CIGNA | OTHER | 1399033 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 20045133 | 01 | PA | AMERIHEALTH MERCY | OTHER | 01901001-02 | 01 | PA | AMERICHOICE- FRANKFORD | OTHER | 1399033 | 01 | PA | PERSONAL CHOICE | OTHER | 00190010010003 | 05 | PA | MEDICAID | 01901001-01 | 01 | PA | AMERICHOICE- TORRES | OTHER | 1164798 | 01 | PA | KEYSTONE MERCY | OTHER | 07645 | 01 | PA | HEALTH PARTNERS | OTHER | 2087612000 | 01 | PA | KEYSTONE IBC | OTHER | 452729 | 01 | PA | AETNA CONTRACT | OTHER | 0019010010002 | 05 | PA | MEDICAID | 01901001-03 | 01 | PA | AMERICHOICE- BUCKS | OTHER |