Provider Demographics
NPI:1629014766
Name:HENRY, MICHAEL P (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:HENRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16533 N STATE HIGHWAY 5 STE 201
Mailing Address - Street 2:
Mailing Address - City:SUNRISE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65079-6769
Mailing Address - Country:US
Mailing Address - Phone:573-374-4600
Mailing Address - Fax:573-374-4608
Practice Address - Street 1:16533 N STATE HIGHWAY 5 STE 201
Practice Address - Street 2:
Practice Address - City:SUNRISE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65079-6769
Practice Address - Country:US
Practice Address - Phone:573-374-4600
Practice Address - Fax:573-374-4608
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2014-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO247988462Medicaid
P01155055OtherRAIL ROAD MEDICARE
MO247988462Medicaid
P01155055OtherRAIL ROAD MEDICARE