Healthcare Provider Details

I. General information

NPI: 1447261201
Provider Name (Legal Business Name): KEITH ALLEN HENRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

5301 VIRGINIA WAY STE 300
BRENTWOOD TN
37027-7542
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-2772
  • Fax:
Mailing address:
  • Phone: 615-221-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number51606
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number54071
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD2020-0138
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number30299
License Number StateWI
# 5
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01092894A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: