1043658677 NPI number — DR. BENNETT ELLEN HARGROVE HENDERSON M.D.

Table of content: DR. BENNETT ELLEN HARGROVE HENDERSON M.D. (NPI 1043658677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043658677 NPI number — DR. BENNETT ELLEN HARGROVE HENDERSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
BENNETT
Provider Middle Name:
ELLEN HARGROVE
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:
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:
1043658677
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2215 NASHVILLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79410-1105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-725-5844
Provider Business Mailing Address Fax Number:
806-723-6532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4102 24TH ST STE 406
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79410-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-725-5790
Provider Business Practice Location Address Fax Number:
806-725-5791
Provider Enumeration Date:
06/05/2013

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: 390200000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: Q9635 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8GX035 . This is a "BCBS TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 582317YKT8 . This is a "TX MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 373353701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1043658677 . This is a "BCBS NM CENTENNIAL" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 44159340 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1043658677 . This is a "FIRSTCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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