MEDICARE: LEE ALLEN HENDERSON MD

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	1035929A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	111890J	OTHER	IN	MEDICARE
3	176600G	OTHER	IN	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000315528	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1417953118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEE ALLEN HENDERSON MD

Provider Business Mailing Address
First Line	:	PO BOX 5628
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47903-5628
Country	:	US
Telephone Number	:	765-448-4319
Fax Number	:	765-448-2921

Provider Business Practice Location Address
First Line	:	2400 SOUTH ST.
Second Line	:	DEPARTMENT OF PATHOLOGY
City	:	LAFAYETTE
State	:	IN
Zip	:	47904
Country	:	US
Telephone Number	:	765-448-4319
Fax Number	:	765-448-2921

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	07/16/2007

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Directions to “ LEE ALLEN HENDERSON MD” Practice Location

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