Provider Demographics
NPI:1215938881
Name:HENNINGER, HEIDI L (MD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:L
Last Name:HENNINGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:49 SPRING ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8926
Practice Address - Country:US
Practice Address - Phone:207-883-1414
Practice Address - Fax:207-883-1518
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD159952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30209407Medicaid
ME336180099Medicaid
MEP01079473Medicare PIN
NH30209407Medicaid
MEMM967201Medicare PIN
ME336180099Medicaid
H72129Medicare UPIN