1710154281 NPI number — PHILIP H. HENDERSON III

Table of content: (NPI 1710154281)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710154281 NPI number — PHILIP H. HENDERSON III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILIP H. HENDERSON III
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PHILIP H. HENDERSON III, M.D., P.S.
Provider Other Organization Name Type Code:
5
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:
1710154281
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 14TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98632-2315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-423-2450
Provider Business Mailing Address Fax Number:
360-425-4969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
790 14TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632-2315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-423-2450
Provider Business Practice Location Address Fax Number:
360-425-4969
Provider Enumeration Date:
05/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KENDALL
Authorized Official First Name:
STELLA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING OFFICE COORDINATOR
Authorized Official Telephone Number:
360-423-2450

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD00018570 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1662907 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: AB33113 . This is a "MEDICARE GROUP PIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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