Provider Demographics
NPI:1497056865
Name:ALBERT E HENDERSON MD PC
Entity Type:Organization
Organization Name:ALBERT E HENDERSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:EBEN
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-258-4075
Mailing Address - Street 1:330 OAK ST
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-4725
Mailing Address - Country:US
Mailing Address - Phone:912-258-4075
Mailing Address - Fax:912-634-2371
Practice Address - Street 1:330 OAK ST
Practice Address - Street 2:
Practice Address - City:SAINT SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-4725
Practice Address - Country:US
Practice Address - Phone:912-258-4075
Practice Address - Fax:912-634-2371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024948207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00261522LMedicaid
GA00261522LMedicaid