Healthcare Provider Details

I. General information

NPI: 1154327856
Provider Name (Legal Business Name): JOHNATHAN EDWARD HENDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 SHORTER AVE NW STE 201
ROME GA
30165
US

IV. Provider business mailing address

420 E 2ND AVE STE 103
ROME GA
30161-3210
US

V. Phone/Fax

Practice location:
  • Phone: 706-509-3300
  • Fax: 706-509-3301
Mailing address:
  • Phone: 706-509-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number054898
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: