Basic Information
| Provider Information | |||||||||
| NPI: | 1003215047 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | DAVID | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 775985 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606775985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177706900 | ||||||||
| FaxNumber: | 3177706911 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 N PERU ST | ||||||||
| Address2: | |||||||||
| City: | CICERO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460349499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179849311 | ||||||||
| FaxNumber: | 3179849302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2014 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10001704A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 241888770 | 05 | IN | MEDICAID |