MEDICARE: DR. VINCENT CHARLES HENDERSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01033656A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	080073934	OTHER	IN	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000588530	OTHER	IN	BCBS BMG E BLAIR WARNER
3	000000085144	OTHER	IN	BCBS BMG MAIN ST
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	000000085145	OTHER	IN	BCBS BMG MEDPOINT IRELAND
6	000000319907	OTHER	IN	BCBS BMG PORTAGE RD

General Provider Information

NPI Number	:	1275521452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VINCENT CHARLES HENDERSON M.D.

Provider Business Mailing Address
First Line	:	710 N NILES AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-1924
Country	:	US
Telephone Number	:	574-647-1610
Fax Number	:

Provider Business Practice Location Address
First Line	:	3575 PORTAGE RD
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-6092
Country	:	US
Telephone Number	:	574-647-4530
Fax Number	:	574-647-4531

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	03/17/2016

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Directions to “ DR. VINCENT CHARLES HENDERSON M.D.” Practice Location

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