Basic Information
| Provider Information | |||||||||
| NPI: | 1467470807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENNING | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 EAST HURON RIVER DRIVE | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481970995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123595 | ||||||||
| FaxNumber: | 7347125344 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 EAST HURON RIVER DRIVE | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481970995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123595 | ||||||||
| FaxNumber: | 7347125344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2085R0001X | 073987 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 4668302 | 05 | MI | MEDICAID |