Basic Information
Provider Information | |||||||||
NPI: | 1326274929 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENRY | ||||||||
FirstName: | JOSHUA | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 699 | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | TN | ||||||||
PostalCode: | 376840699 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234336039 | ||||||||
FaxNumber: | 4234336060 | ||||||||
Practice Location | |||||||||
Address1: | 325 N. STATE OF FRANKLIN ROAD, GROUND FLOOR | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 37604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234397320 | ||||||||
FaxNumber: | 4234397343 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2009 | ||||||||
LastUpdateDate: | 08/01/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 46043 | KY | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 31732 | SC | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 54572 | TN | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 7100332640 | 05 | KY |   | MEDICAID | 201281690 | 05 | IN |   | MEDICAID | 1326274929 | 05 | VA |   | MEDICAID | 317320 | 05 | SC |   | MEDICAID | Q023478 | 05 | TN |   | MEDICAID |