Healthcare Provider Details

I. General information

NPI: 1144450792
Provider Name (Legal Business Name): PHILLIP HENDERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 S UNIVERSITY BLVD UCOM 6000B
MOBILE AL
36688-0002
US

IV. Provider business mailing address

PO BOX 40480
MOBILE AL
36640-0480
US

V. Phone/Fax

Practice location:
  • Phone: 251-660-5555
  • Fax: 251-660-5559
Mailing address:
  • Phone: 251-660-5555
  • Fax: 251-660-5559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO1151
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberDO.1151
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: