Provider Demographics
NPI:1720083066
Name:HENTHORN, RAYMOND BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:BRUCE
Last Name:HENTHORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:R
Other - Middle Name:BRUCE
Other - Last Name:HENTHORN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:316 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-3027
Mailing Address - Country:US
Mailing Address - Phone:740-374-3556
Mailing Address - Fax:740-374-3577
Practice Address - Street 1:316 5TH ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3027
Practice Address - Country:US
Practice Address - Phone:740-374-3556
Practice Address - Fax:740-374-3577
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 048319207PE0004X
WV12681207PE0004X
OH350483192083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0050235000Medicaid
OH0539939Medicaid
D33265Medicare UPIN
OH0539939Medicaid