Basic Information
| Provider Information | |||||||||
| NPI: | 1912995713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11449 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797091924 | ||||||||
| FaxNumber: | 4797097499 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 DODSON AVE | ||||||||
| Address2: | STE 280 | ||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729015182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797097480 | ||||||||
| FaxNumber: | 4797097479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 11/23/2016 | ||||||||
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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 | 207RN0300X | C6617 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 17047 | OK | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 115766001 | 05 | AR | MEDICAID | 100080640A | 05 | OK | MEDICAID |