Healthcare Provider Details

I. General information

NPI: 1760452577
Provider Name (Legal Business Name): KENDRICK KNOLL HENDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 CENTERVIEW PKWY STE 500
CORDOVA TN
38018-4254
US

IV. Provider business mailing address

8000 CENTERVIEW PKWY STE 500
CORDOVA TN
38018-4254
US

V. Phone/Fax

Practice location:
  • Phone: 901-747-1111
  • Fax: 901-255-7168
Mailing address:
  • Phone: 901-747-1111
  • Fax: 901-255-7168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number36334
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3873403
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer
# 2
Identifier3703553
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: