Healthcare Provider Details

I. General information

NPI: 1841370707
Provider Name (Legal Business Name): MARK A HENDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 17TH ST
COLUMBUS IN
47201-5351
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-376-5550
  • Fax: 812-376-5930
Mailing address:
  • Phone: 812-376-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number01061526A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: