Healthcare Provider Details

I. General information

NPI: 1477541654
Provider Name (Legal Business Name): ALBERTA LEE HENDERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 N MICHIGAN ST
SOUTH BEND IN
46601-1035
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-284-7477
  • Fax:
Mailing address:
  • Phone: 574-647-1070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01043140A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: