Active NPI
Vincent Charles Henderson, M.D.
- Family Medicine Physician
- South Bend, IN
National Provider Identifier
1275521452
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 01033656A
- Practice address
- 3575 Portage Rd
South Bend, IN 46628-6092 - Phone
- (574) 647-4530
- Fax
- (574) 647-4531
- NPI assigned
- Oct 11, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 01033656A | IN | Primary |
Addresses
Primary practice location
3575 Portage Rd
South Bend, IN 46628-6092
Mailing address
710 N Niles Ave
South Bend, IN 46617-1924
Phone (574) 647-1610
Other identifiers 6
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 000000588530 | Other | IN | BCBS BMG E BLAIR WARNER |
| 080073934 | Other | IN | RR MEDICARE |
| 000000085144 | Other | IN | BCBS BMG MAIN ST |
| 200064640 | Medicaid | IN | |
| 000000085145 | Other | IN | BCBS BMG MEDPOINT IRELAND |
| 000000319907 | Other | IN | BCBS BMG PORTAGE RD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 01033656A | IN | MD | Family Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1128988800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1458172800000",
"number": "1275521452",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "710 N NILES AVE",
"city": "SOUTH BEND",
"state": "IN",
"postal_code": "466171924",
"telephone_number": "574-647-1610"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3575 PORTAGE RD",
"city": "SOUTH BEND",
"state": "IN",
"postal_code": "466286092",
"telephone_number": "574-647-4530",
"fax_number": "574-647-4531"
}
],
"practiceLocations": [],
"basic": {
"last_name": "HENDERSON",
"first_name": "VINCENT",
"middle_name": "CHARLES",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-10-11",
"last_updated": "2016-03-17",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "IN",
"license": "01033656A",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS BMG E BLAIR WARNER",
"identifier": "000000588530",
"state": "IN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RR MEDICARE",
"identifier": "080073934",
"state": "IN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS BMG MAIN ST",
"identifier": "000000085144",
"state": "IN"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "200064640",
"state": "IN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS BMG MEDPOINT IRELAND",
"identifier": "000000085145",
"state": "IN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS BMG PORTAGE RD",
"identifier": "000000319907",
"state": "IN"
}
],
"endpoints": [],
"other_names": []
}Other providers in South Bend, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.