Basic Information
Provider Information | |||||||||
NPI: | 1962670430 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENRY | ||||||||
FirstName: | LESHA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CST | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8333 NAAB RD | ||||||||
Address2: | SUITE 255 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462605924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7654488000 | ||||||||
FaxNumber: | 7654487612 | ||||||||
Practice Location | |||||||||
Address1: | 2600 FERRY ST | ||||||||
Address2: | INDIANAPOLIS NEUROSURGICAL GROUP | ||||||||
City: | LAFAYETTE | ||||||||
State: | IN | ||||||||
PostalCode: | 479043055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7654488000 | ||||||||
FaxNumber: | 7654487612 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/18/2008 | ||||||||
LastUpdateDate: | 07/13/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | 93967 | IN | Y |   |   |   |   |
No ID Information.