Basic Information
| Provider Information | |||||||||
| NPI: | 1427050491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 PEACHTREE RD NE | ||||||||
| Address2: | STE 705 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043550743 | ||||||||
| FaxNumber: | 4043552136 | ||||||||
| Practice Location | |||||||||
| Address1: | 5505 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | STE 600 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043550743 | ||||||||
| FaxNumber: | 4049430641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 08/12/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 030474 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 030474 | GA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0486290001 | 01 | DME | OTHER | 00458653C | 05 | GA | MEDICAID |