Healthcare Provider Details

I. General information

NPI: 1700377033
Provider Name (Legal Business Name): JULIAN HENDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W COURT ST STE 214
KANKAKEE IL
60901-3674
US

IV. Provider business mailing address

555 W COURT ST STE 214
KANKAKEE IL
60901-3674
US

V. Phone/Fax

Practice location:
  • Phone: 815-928-6131
  • Fax:
Mailing address:
  • Phone: 815-928-6131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLP04240
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number036165552
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036165552
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: