Provider Demographics
NPI:1174556088
Name:HENNIG, NILS (MD)
Entity type:Individual
Prefix:
First Name:NILS
Middle Name:
Last Name:HENNIG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUSTAVE L LEVY PL # 1403
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6504
Mailing Address - Country:US
Mailing Address - Phone:212-824-7033
Mailing Address - Fax:212-824-2327
Practice Address - Street 1:1 GUSTAVE L LEVY PL # 1403
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6504
Practice Address - Country:US
Practice Address - Phone:212-824-7033
Practice Address - Fax:212-824-2327
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222774208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02690191Medicaid
NY5330QEMedicare PIN
NY02690191Medicaid