Provider Demographics
NPI:1366515363
Name:HENSON, TARA HOPE (MD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:HOPE
Last Name:HENSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:42743-1429
Mailing Address - Country:US
Mailing Address - Phone:270-299-2286
Mailing Address - Fax:270-299-2157
Practice Address - Street 1:310 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:KY
Practice Address - Zip Code:42743-1429
Practice Address - Country:US
Practice Address - Phone:270-299-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100023460Medicaid
KYK018843OtherMEDICARE
0952010Medicare PIN
00151005Medicare PIN
0771918Medicare PIN
0745825Medicare PIN
KYP00404549Medicare PIN
0935385Medicare PIN
KYR1228OtherTEMP LICENSE
0903679Medicare PIN
0396856Medicare PIN
0683238Medicare PIN