Provider Demographics
NPI:1528058765
Name:HENDERSON, REGGIE ALLAN (MD)
Entity type:Individual
Prefix:DR
First Name:REGGIE
Middle Name:ALLAN
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-2038
Mailing Address - Country:US
Mailing Address - Phone:731-968-3646
Mailing Address - Fax:731-968-1870
Practice Address - Street 1:200 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-2038
Practice Address - Country:US
Practice Address - Phone:731-968-3646
Practice Address - Fax:731-968-1870
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12019207P00000X, 207R00000X, 208000000X, 208100000X, 2085R0202X, 208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4057341OtherBLUE CROSS BLUE SHIELD
TN626001636OtherUSA MANAGED CARE
TN152666OtherUNISON
TNJT1012OtherCIGNA
TNP00034973OtherRAILROAD MEDICARE
TN3189726Medicaid
TN626001636OtherHEALTH PARTNERS
TN27415OtherTLC
TN626001636OtherUNITED HEALTHCARE
TN27415OtherTLC
TNP00034973OtherRAILROAD MEDICARE
TNB04393Medicare UPIN
TN3189720Medicare ID - Type Unspecified