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NPI Code Detail

MEDICARE: BRYAN HENDERSON MD

MEDICARE: BRYAN HENDERSON MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207P00000XEmergency Medicine Physician0425215KS

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1102509OTHERKSBLUE CROSS BLUE SHIELD
2432140OTHERKSFIRST GUARD

General Provider Information

NPI Number : 1114983988
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRYAN HENDERSON MD
Provider Business Mailing Address
First Line : 6896 W SNOWVILLE RD
Second Line :
City : BRECKSVILLE
State : OH
Zip : 44141-3214
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1701 E 23RD AVE
Second Line :
City : HUTCHINSON
State : KS
Zip : 67502-1105
Country : US
Telephone Number : 620-665-2587
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/21/2006
Last Update Date : 12/06/2007

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