Provider Demographics
NPI:1285689091
Name:HENDERSON, ELLENA (MD)
Entity Type:Individual
Prefix:
First Name:ELLENA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 UNION AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1325 EASTMORELAND AVE STE 245
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3591
Practice Address - Country:US
Practice Address - Phone:901-516-9800
Practice Address - Fax:901-516-9817
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39177207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00279007OtherRR MEDICARE
TN4097866OtherBCBS
TN3716661Medicaid
TN4097866OtherBCBS
TNP00279007OtherRR MEDICARE