Provider Demographics
NPI:1366601106
Name:DR. MILLARD T. HENNESSEE, P.C.
Entity type:Organization
Organization Name:DR. MILLARD T. HENNESSEE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MILLARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:HENNESSEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-268-1745
Mailing Address - Street 1:654 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1502
Mailing Address - Country:US
Mailing Address - Phone:617-268-1745
Mailing Address - Fax:617-268-1748
Practice Address - Street 1:654 E BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-1502
Practice Address - Country:US
Practice Address - Phone:617-268-1745
Practice Address - Fax:617-268-1748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA001614213EP1101X
MA1614332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY70691Medicare Oscar/Certification
MA0220530001Medicare NSC