1568404416 NPI number — POLLY A HENDERSON MD

Table of content: POLLY A HENDERSON MD (NPI 1568404416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568404416 NPI number — POLLY A HENDERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
POLLY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1568404416
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3495 PIEDMONT RD NE
Provider Second Line Business Mailing Address:
NINE PIEDMONT CENTER
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30305-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-364-7070
Provider Business Mailing Address Fax Number:
215-255-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3650 STEVE REYNOLDS BLVD
Provider Second Line Business Practice Location Address:
KAISER PERMANENTE GWINNETT MEDICAL CENTER
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30096-4506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-762-3937
Provider Business Practice Location Address Fax Number:
215-762-5600
Provider Enumeration Date:
06/12/2006

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: 207W00000X , with the licence number:  MD425936 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 068190 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101262870 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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