Healthcare Provider Details

I. General information

NPI: 1578546412
Provider Name (Legal Business Name): CLYDE E HENDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 SMITH RD SUITE B
NORWOOD OH
45212-2793
US

IV. Provider business mailing address

PO BOX 637783
CINCINNATI OH
45263-7783
US

V. Phone/Fax

Practice location:
  • Phone: 513-221-4848
  • Fax: 513-872-7825
Mailing address:
  • Phone: 513-853-4749
  • Fax: 513-853-4740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number35042182
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number35042182
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: