Provider Demographics
NPI:1841737277
Name:DR HENDERSON JUDY MD FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:DR HENDERSON JUDY MD FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-683-0330
Mailing Address - Street 1:24 N SAINT JOSEPH AVE
Mailing Address - Street 2:SUITE C 2
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2263
Mailing Address - Country:US
Mailing Address - Phone:269-683-0330
Mailing Address - Fax:269-684-0400
Practice Address - Street 1:24 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE C 2
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2263
Practice Address - Country:US
Practice Address - Phone:269-683-0330
Practice Address - Fax:269-684-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088108207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1101111081OtherBLUE CROSS BLUE SHIELD
MI1700813227Medicaid
0111108OtherBCBS
MIH06000080Medicare PIN
MI1700813227Medicaid