Basic Information
| Provider Information | |||||||||
| NPI: | 1194705574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | LEWIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6262 VETERANS PKWY | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319093540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064943071 | ||||||||
| FaxNumber: | 7064943201 | ||||||||
| Practice Location | |||||||||
| Address1: | 4689 US HIGHWAY 17 | ||||||||
| Address2: | SUITE 11 &12 | ||||||||
| City: | FLEMING ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320034831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043759753 | ||||||||
| FaxNumber: | 9043758380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 07/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME54173 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0801X | ME54173 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
No ID Information.