Provider Demographics
NPI:1760798839
Name:RAYMOND HENDERSON MD PA
Entity Type:Organization
Organization Name:RAYMOND HENDERSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-804-9898
Mailing Address - Street 1:1717 N FLAGLER DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-6555
Mailing Address - Country:US
Mailing Address - Phone:561-804-9898
Mailing Address - Fax:561-804-9049
Practice Address - Street 1:1717 N FLAGLER DR
Practice Address - Street 2:SUITE 3
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-6555
Practice Address - Country:US
Practice Address - Phone:561-804-9898
Practice Address - Fax:561-804-9049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59588208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055398100Medicaid
FLF01226Medicare UPIN