=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720095664
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS HENDERSON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2006
-----------------------------------------------------
Last Update Date | 05/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 618 HOSPITAL RD
-----------------------------------------------------
City | TAPPAHANNOCK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22560-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-963-1655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1816
-----------------------------------------------------
City | TAPPAHANNOCK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22560-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-963-1655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 25MA05596700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------