Basic Information
| Provider Information | |||||||||
| NPI: | 1568569085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | REID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 DELAWARE ST SE | ||||||||
| Address2: | MMC 295 - UNIV MINNESOTA NEUROLOGY | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126259900 | ||||||||
| FaxNumber: | 6126257950 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 DELAWARE ST SE | ||||||||
| Address2: | MMC 295 - UNIV MINNESOTA NEUROLOGY | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126259900 | ||||||||
| FaxNumber: | 6126257950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2006 | ||||||||
| LastUpdateDate: | 05/29/2012 | ||||||||
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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 | 2084N0400X | 038795 | GA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 026400-8 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 00612708A | 05 | GA | MEDICAID |