Provider Demographics
NPI:1114983988
Name:HENDERSON, BRYAN (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:HENDERSON
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 1:6896 W SNOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-3214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 E 23RD AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-1105
Practice Address - Country:US
Practice Address - Phone:620-665-2587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0425215207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS102509OtherBLUE CROSS BLUE SHIELD
KS432140OtherFIRST GUARD
KS432140OtherFIRST GUARD
KSF91682Medicare UPIN