Provider Demographics
NPI:1639220866
Name:HENRY, NEIL C (MD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:C
Last Name:HENRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2904 JOHNSON ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2234
Mailing Address - Country:US
Mailing Address - Phone:612-788-0900
Mailing Address - Fax:612-788-4930
Practice Address - Street 1:2904 JOHNSON ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-2234
Practice Address - Country:US
Practice Address - Phone:612-788-0900
Practice Address - Fax:612-788-4930
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19172207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080161602OtherRAILROAD MEDICARE
MN0111978OtherMEDICA
MN55B82HEOtherBLUES
MN637877300Medicaid
MN80483OtherHEALTHPARTNERS
MN00687002OtherPREFERRED ONE
MN103052OtherUCARE
MN637877300Medicaid
MN0111978OtherMEDICA