MEDICARE: AUDREY HENDERSON M.D.P.C.

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	174400000X	Specialist	029884	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	GRP6154	OTHER	GA	MEDICARE GROUP #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386825222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUDREY HENDERSON M.D.P.C.

Provider Business Mailing Address
First Line	:	2824 HILL CREEK DRIVE
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909
Country	:	US
Telephone Number	:	706-860-4567
Fax Number	:	706-860-4489

Provider Business Practice Location Address
First Line	:	2824 HILLCREEK DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-5628
Country	:	US
Telephone Number	:	706-860-4567
Fax Number	:	706-860-4489

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AUDREY M. HENDERSON
Credential	:	M.D.
Telephone Number	:	706-860-4567

Provider Enumeration Date	:	11/20/2007
Last Update Date	:	11/20/2007

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