Provider Demographics
NPI:1225342553
Name:ROBERT C HENDERSON MD PA
Entity Type:Organization
Organization Name:ROBERT C HENDERSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CONNAR
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-879-6603
Mailing Address - Street 1:4600 N HABANA AVE
Mailing Address - Street 2:30
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7112
Mailing Address - Country:US
Mailing Address - Phone:813-879-6603
Mailing Address - Fax:813-879-6805
Practice Address - Street 1:4600 N HABANA AVE
Practice Address - Street 2:30
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7112
Practice Address - Country:US
Practice Address - Phone:813-879-6603
Practice Address - Fax:813-879-6805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0036678207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067431100Medicaid
FL30306Medicare PIN
FL067431100Medicaid