Provider Demographics
NPI:1013019652
Name:HENRY, BERTRAM R (MD)
Entity Type:Individual
Prefix:
First Name:BERTRAM
Middle Name:R
Last Name:HENRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 S PETERS RD STE 101
Mailing Address - Street 2:KNOXVILLE
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-5229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:214 S PETERS RD
Practice Address - Street 2:101
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-5229
Practice Address - Country:US
Practice Address - Phone:865-539-1001
Practice Address - Fax:865-693-6393
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000083052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3154067Medicaid
TNB02499Medicare UPIN
TN3154067Medicaid