Provider Demographics
NPI:1316021827
Name:HENRY, WILLIAM J (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
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:PO BOX 8500-6335
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-6335
Mailing Address - Country:US
Mailing Address - Phone:215-612-5390
Mailing Address - Fax:215-612-5658
Practice Address - Street 1:3998 RED LION RD
Practice Address - Street 2:SUITE 204
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1445
Practice Address - Country:US
Practice Address - Phone:215-612-5390
Practice Address - Fax:215-612-5658
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033208E207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011874410005Medicaid
PA4131823OtherAETNA PPO
PA0091405000OtherKEYSTONE IBC
PA30124827OtherKEYSTONE FIRST
PAHE 192740OtherBLUE SHIELD
PA7508097OtherAETNA HMO
PA192740Q0SMedicare PIN
PAHE 192740OtherBLUE SHIELD