Provider Demographics
NPI:1982827945
Name:HENDERSON MEDICAL CLINIC, PA
Entity Type:Organization
Organization Name:HENDERSON MEDICAL CLINIC, PA
Other - Org Name:ABERNATHY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:BBA
Authorized Official - Phone:806-771-1166
Mailing Address - Street 1:409 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ABERNATHY
Mailing Address - State:TX
Mailing Address - Zip Code:79311-3416
Mailing Address - Country:US
Mailing Address - Phone:806-298-5884
Mailing Address - Fax:806-298-5889
Practice Address - Street 1:409 8TH ST
Practice Address - Street 2:
Practice Address - City:ABERNATHY
Practice Address - State:TX
Practice Address - Zip Code:79311-3416
Practice Address - Country:US
Practice Address - Phone:806-298-5884
Practice Address - Fax:806-298-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5115207R00000X
261QR1300X
TX533693363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX67-3910Medicare PIN