MEDICARE: DR. ROBERT LAND HENDERSON JR. 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	207N00000X	Dermatology Physician	00025681	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51532549	OTHER	AL	BCBS

General Provider Information

NPI Number	:	1306833041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT LAND HENDERSON JR. MD

Provider Business Mailing Address
First Line	:	1022 1ST ST N
Second Line	:	SUITE 201
City	:	ALABASTER
State	:	AL
Zip	:	35007-8706
Country	:	US
Telephone Number	:	205-621-9500
Fax Number	:	205-621-9507

Provider Business Practice Location Address
First Line	:	1022 1ST ST N
Second Line	:	SUITE 201
City	:	ALABASTER
State	:	AL
Zip	:	35007-8706
Country	:	US
Telephone Number	:	205-621-9500
Fax Number	:	205-621-9507

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

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	12/20/2012

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