Provider Demographics
NPI:1750494472
Name:HENDERSON, ANITA S (MD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:S
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-3735
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:101 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-579-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13283208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1685887Medicaid
MS00117288Medicaid
MS1559044OtherAMERICAN ADMIN GROUP
MS1559044OtherAMERICAN ADMIN GROUP
F97164Medicare UPIN
MS370000229Medicare PIN
MS1559044OtherAMERICAN ADMIN GROUP