Provider Demographics
NPI:1578721866
Name:HENDERSON, THOMAS JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JAMES
Last Name:HENDERSON
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 1:913 N DIXIE AVE
Mailing Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2503
Mailing Address - Country:US
Mailing Address - Phone:877-783-6257
Mailing Address - Fax:
Practice Address - Street 1:913 N DIXIE AVE
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2503
Practice Address - Country:US
Practice Address - Phone:877-783-6257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068464A207P00000X
PAMT188168207P00000X
KY45465207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000766878OtherBCBS
KY7100174620Medicaid
IN200987820Medicaid
KY50037788OtherPASSPORT
KY7100174620Medicaid