Provider Demographics
NPI:1760452577
Name:HENDERSON, KENDRICK KNOLL (MD)
Entity Type:Individual
Prefix:
First Name:KENDRICK
Middle Name:KNOLL
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 1:8000 CENTERVIEW PKWY STE 500
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4254
Mailing Address - Country:US
Mailing Address - Phone:901-747-1111
Mailing Address - Fax:901-255-7168
Practice Address - Street 1:8000 CENTERVIEW PKWY STE 500
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4254
Practice Address - Country:US
Practice Address - Phone:901-747-1111
Practice Address - Fax:901-255-7168
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN363342084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3873403Medicaid
TN3703553Medicaid
TN3703553Medicare PIN
TNG84657Medicare UPIN
G84657Medicare UPIN
TN3873403Medicaid