Healthcare Provider Details

I. General information

NPI: 1811947070
Provider Name (Legal Business Name): HENDERSONS MINOR OUTPATIENT MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 N ELM ST
HENDERSON KY
42420-2712
US

IV. Provider business mailing address

1015 N ELM ST
HENDERSON KY
42420-2712
US

V. Phone/Fax

Practice location:
  • Phone: 270-826-8009
  • Fax: 270-826-7010
Mailing address:
  • Phone: 270-826-8009
  • Fax: 270-826-7010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID WATKINS
Title or Position: PARTNER
Credential: M.D.
Phone: 270-826-8009