Provider Demographics
NPI:1881659191
Name:HENRY, MARY ANN C (MD)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:C
Last Name:HENRY
Suffix:
Gender:F
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1930 BISHOP LN STE 1600
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-1948
Practice Address - Country:US
Practice Address - Phone:502-272-5044
Practice Address - Fax:502-272-5121
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21463207R00000X
IN01034115A207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000026447GOtherHUMANA / NCMA
KY110154477OtherRAILROAD MEDICARE
50015294OtherPASSPORT / NCMA
KY64214638Medicaid
1193602OtherCHA / NCMA
21433721000OtherPASSPORT ADVANTAGE / NCMA
IN100360840Medicaid
2560873002OtherCIGNA
00000050975OtherANTHEM / NCMA
008918OtherSIHO / NCMA
008918OtherSIHO / NCMA
21433721000OtherPASSPORT ADVANTAGE / NCMA
KY0361908Medicare PIN