Provider Demographics
NPI:1770686933
Name:DOUGLAS J HENKE MD PC
Entity Type:Organization
Organization Name:DOUGLAS J HENKE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:JON
Authorized Official - Last Name:HENKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-779-4270
Mailing Address - Street 1:1711 S STEPHENSON AVE
Mailing Address - Street 2:SUITE 125
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3639
Mailing Address - Country:US
Mailing Address - Phone:906-779-4270
Mailing Address - Fax:906-779-4276
Practice Address - Street 1:1711 S STEPHENSON AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3639
Practice Address - Country:US
Practice Address - Phone:906-779-4270
Practice Address - Fax:906-779-4276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30730800Medicaid
MI3285138Medicaid
WI30730800Medicaid