Provider Demographics
NPI:1316963358
Name:HENDERSON, PHILIP NORTON (MD, MPH, MBA)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:NORTON
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD, MPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2696 LAWRENCEVILLE-SUWANEE RD
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024
Mailing Address - Country:US
Mailing Address - Phone:678-376-1300
Mailing Address - Fax:
Practice Address - Street 1:2696 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2535
Practice Address - Country:US
Practice Address - Phone:678-376-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047601261QP2300X, 261QU0200X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA047601OtherSTATE LICENSE NUMBER
GA00851034CMedicaid
GA00851034CMedicaid
GA047601OtherSTATE LICENSE NUMBER
GAAH3198682OtherFEDERAL DEA NUMBER
GA00851034CMedicaid