1013966423 NPI number — DR. MELINDA SHAW HENDERSON M.D.

Table of content: CANDICE HENRY (NPI 1699598920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013966423 NPI number — DR. MELINDA SHAW HENDERSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
MELINDA
Provider Middle Name:
SHAW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHAW
Provider Other First Name:
MELINDA
Provider Other Middle Name:
PATRICIA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013966423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
926 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37206-3614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-436-9060
Provider Business Mailing Address Fax Number:
615-235-9725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
926 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37206-3614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-436-9060
Provider Business Practice Location Address Fax Number:
615-235-9725
Provider Enumeration Date:
05/10/2006

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: 207R00000X , with the licence number:  101269980 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: MD-46979 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: ME145469 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: S7231 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 04-44655 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X , with the licence number: 39361 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0002X , with the licence number: 39361 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 39361 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3327126 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201357160A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 250696062 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013966423 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001422 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 109478800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013966423 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013966423 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 422491701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 98639757 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013966423 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1040492810001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64095060 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39361 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 0131691 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0425399 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110171810A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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