Basic Information
| Provider Information | |||||||||
| NPI: | 1194710467 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENNESSY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 ALCOA HWY | ||||||||
| Address2: | STE 435 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653058888 | ||||||||
| FaxNumber: | 8653057090 | ||||||||
| Practice Location | |||||||||
| Address1: | 1924 ALCOA HWY | ||||||||
| Address2: | SUITE 6-SOUTH | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653058888 | ||||||||
| FaxNumber: | 8653052514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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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 | 207VM0101X | MD 23608 | TN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3069396 | 05 | TN | MEDICAID |