=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043287634
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENRY H CHEN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2006
-----------------------------------------------------
Last Update Date | 12/04/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | GOOD SAMARITAN REGIONAL HEALTH CENTER 605 N 12 ST
-----------------------------------------------------
City | MT VERNON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-242-4600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 622 S DEER LAKE DR E
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62901-5256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-351-0115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------