Provider Demographics
NPI:1730125428
Name:HENNE, TIMOTHY D (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:D
Last Name:HENNE
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 1:1111 LEFFINGWELL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2373 64TH ST SW STE 2700
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-7978
Practice Address - Country:US
Practice Address - Phone:616-465-5910
Practice Address - Fax:616-465-5911
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072748207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4630898Medicaid
MIH89803Medicare UPIN
MI4630898Medicaid