Provider Demographics
NPI:1669648226
Name:HENDERSON LAB AND XRAY
Entity Type:Organization
Organization Name:HENDERSON LAB AND XRAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/THE HEART GROUP
Authorized Official - Prefix:DR
Authorized Official - First Name:SATYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:TATINENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-464-0521
Mailing Address - Street 1:PO BOX 3316
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47732-3316
Mailing Address - Country:US
Mailing Address - Phone:812-464-0521
Mailing Address - Fax:812-464-0565
Practice Address - Street 1:1413 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2768
Practice Address - Country:US
Practice Address - Phone:270-826-6277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE HEART GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200135291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY37903820Medicaid
KY4014201Medicare PIN