Provider Demographics
NPI:1558767509
Name:HENDERSON, RUGH I
Entity Type:Individual
Prefix:
First Name:RUGH
Middle Name:
Last Name:HENDERSON
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 STAUFFERS CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:PA
Mailing Address - Zip Code:17078-9607
Mailing Address - Country:US
Mailing Address - Phone:717-838-5961
Mailing Address - Fax:
Practice Address - Street 1:945 STAUFFERS CHURCH RD
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:PA
Practice Address - Zip Code:17078-9607
Practice Address - Country:US
Practice Address - Phone:717-838-5961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD008753E207Q00000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine