=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275648750
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAYMOND HENDERSON SR. M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 11/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 N FLAGLER DR SUITE 7300
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33401-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-804-9898
-----------------------------------------------------
Fax | 561-804-9049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2234 COLONIAL BLVD ATTN: PAYER CONTRACTING & RELATIONS DEPT.
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-1412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-931-7342
-----------------------------------------------------
Fax | 239-931-7385
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | ME59588
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------