Provider Demographics
NPI:1982751848
Name:HENDERSON, CARRIE MORGAN (MD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:MORGAN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:INGRAM
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DEPT OF PEDIATRICS
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5214
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5214
Practice Address - Fax:601-984-6439
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.093662208000000X
MS220922080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2359681Medicaid
MS302I819921Medicare PIN
LA2359681Medicaid