Healthcare Provider Details

I. General information

NPI: 1629014766
Provider Name (Legal Business Name): MICHAEL P HENRY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 03/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16533 N STATE HIGHWAY 5 STE 201
SUNRISE BEACH MO
65079-6769
US

IV. Provider business mailing address

16533 N STATE HIGHWAY 5 STE 201
SUNRISE BEACH MO
65079-6769
US

V. Phone/Fax

Practice location:
  • Phone: 573-374-4600
  • Fax: 573-374-4608
Mailing address:
  • Phone: 573-374-4600
  • Fax: 573-374-4608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number106206
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: