Basic Information
| Provider Information | |||||||||
| NPI: | 1154327856 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | JOHNATHAN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E 2ND AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 304 SHORTER AVE NW STE 201 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093300 | ||||||||
| FaxNumber: | 7065093301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 054898 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0103487 | 01 | GA | UNITED HEALTHCARE | OTHER | 6313 | 01 | GA | KAISER PERMANENTE | OTHER | P00177381 | 01 | GA | RAILROAD RETIREMENT MEDIC | OTHER | 388021 | 01 | GA | BCBS | OTHER |