Provider Demographics
NPI:1861423196
Name:HENNESSEY, THOMAS W (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:HENNESSEY
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 1:3001 METRO DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4506
Mailing Address - Country:US
Mailing Address - Phone:952-814-6600
Mailing Address - Fax:
Practice Address - Street 1:2800 CHICAGO AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1318
Practice Address - Country:US
Practice Address - Phone:952-814-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22165207PE0004X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Not Answered2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA94545Medicare UPIN