MEDICARE: DR. MARK T 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
1	207P00000X	Emergency Medicine Physician	33009	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	33009	OTHER	KY	KENTUCKY LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255372868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK T HENDERSON MD

Provider Business Mailing Address
First Line	:	812 S 3RD ST
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40203-2214
Country	:	US
Telephone Number	:	502-290-2501
Fax Number	:	502-287-1775

Provider Business Practice Location Address
First Line	:	812 S 3RD ST
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40203-2214
Country	:	US
Telephone Number	:	502-290-2501
Fax Number	:	502-287-1775

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	12/19/2024

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