NPIMap

Individual provider Active NPI

Edward Daniel Henderson Jr., M.D.

  • Family Medicine Physician
  • Collinsville, MS
National Provider Identifier
1346222890
Registry record updated Nov 6, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
16698 Issued in MS
Practice address
9097 Collinsville Rd
Collinsville, MS 39325-9779
Phone
(601) 626-8874
Fax
(601) 626-8592
NPI assigned
Nov 18, 2005
Last updated
Nov 6, 2013By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 6, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 16698 MS Primary

Addresses

Primary practice location

9097 Collinsville Rd
Collinsville, MS 39325-9779

Mailing address

PO Box 2106
Meridian, MS 39302-2106
Phone (601) 703-4282

Other identifiers 2

IdentifierTypeStateIssuer
00121878MedicaidMS
730-14734OtherBLUE CROSS OF AL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040120000522 MS Practitioner - Family Practice 6103723713 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Miami, LM Miller School of Medicine, 1993
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Laird Hospital, Inc.Group PAC ID 7214991769, 30 clinicians

Practice addresses (Care Compare)

9097 Collinsville Rd
Collinsville, MS 39325-9779
Phone (601) 626-8874

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
16698MSMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Kemper Cah, Inc. CurrentSince Mar 5, 2021 Accepting new patients
Laird Hospital, Inc. CurrentSince Jun 1, 2013 Accepting new patients
Laird Hospital, Inc. CurrentSince Jun 1, 2013 Accepting new patients

Locations

9097 Collinsville Rd
Collinsville, MS 39325
Phone (601) 626-8874

14365 Highway 16 W
De Kalb, MS 39328
Phone (769) 486-1000

5334 Dale Dr
Marion, MS 39342
Phone (601) 703-0130

1314 19th Ave
Meridian, MS 39301
Phone (601) 483-0011

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 10

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1132272000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1383696000000",
    "number": "1346222890",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2106",
            "city": "MERIDIAN",
            "state": "MS",
            "postal_code": "393022106",
            "telephone_number": "601-703-4282",
            "fax_number": "601-703-4597"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9097 COLLINSVILLE RD",
            "city": "COLLINSVILLE",
            "state": "MS",
            "postal_code": "393259779",
            "telephone_number": "601-626-8874",
            "fax_number": "601-626-8592"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "HENDERSON",
        "first_name": "EDWARD",
        "middle_name": "DANIEL",
        "name_prefix": "Dr.",
        "name_suffix": "Jr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-11-18",
        "last_updated": "2013-11-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MS",
            "license": "16698",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00121878",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF AL",
            "identifier": "730-14734",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Collinsville, MS

Sources for this page

Verify at the official NPI Registry.