Basic Information
| Provider Information | |||||||||
| NPI: | 1861426694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 869 | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460610869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177706900 | ||||||||
| FaxNumber: | 3177706911 | ||||||||
| Practice Location | |||||||||
| Address1: | 14535A HAZEL DELL PKWY | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460339401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177054360 | ||||||||
| FaxNumber: | 3177054361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207Q00000X | 036-104711 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01075456A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 036104711 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | 01075456A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036104711 | 05 | IL | MEDICAID | 201291730 | 05 | IN | MEDICAID |