Provider Demographics
NPI:1851463228
Name:HENDERSON, REUBEN S (DO)
Entity Type:Individual
Prefix:
First Name:REUBEN
Middle Name:S
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3936 PATIENT CARE DRIVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911
Mailing Address - Country:US
Mailing Address - Phone:517-853-2767
Mailing Address - Fax:517-853-2988
Practice Address - Street 1:3937 PATIENT CARE WAY
Practice Address - Street 2:SUITE 107
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4287
Practice Address - Country:US
Practice Address - Phone:517-853-2767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012141208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG58751Medicare UPIN
0N99820Medicare ID - Type Unspecified