Basic Information
| Provider Information | |||||||||
| NPI: | 1639139876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | SHEA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 PLAZA DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638015136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734726003 | ||||||||
| FaxNumber: | 5734727159 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 PLAZA DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638015136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734726003 | ||||||||
| FaxNumber: | 5734727159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 01/24/2012 | ||||||||
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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 | 208600000X | J4200 | TX | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8BF145 | 01 | TX | BCBS | OTHER | 113358901 | 05 | TX | MEDICAID | 113358905 | 05 | TX | MEDICAID | 113358906 | 05 | TX | MEDICAID | 113358907 | 05 | TX | MEDICAID | 990010000 | 01 | TX | MCARE RR | OTHER |