1578534756 NPI number — BRENT N HENDERSON PHD

Table of content: BRENT N HENDERSON PHD (NPI 1578534756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578534756 NPI number — BRENT N HENDERSON PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
BRENT
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578534756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 HOT METAL ST
Provider Second Line Business Mailing Address:
QUANTUM ONE, N430
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15203-2348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-432-7706
Provider Business Mailing Address Fax Number:
412-432-7691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5115 CENTRE AVE
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15232-1301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-623-5888
Provider Business Practice Location Address Fax Number:
412-623-5980
Provider Enumeration Date:
01/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PS015211 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 520447 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11440288 . This is a "CAQH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001905341 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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