Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208G00000X | Cardiothoracic Vascular Surgeon | 40239 | KY |
NPI | 1003020561 |
---|---|
Provider Name | Dr. Scott Eric Henry |
First Address | Hattiesburg, MS 39402-1331 |
Second Address | Hattiesburg, MS 39402-1331 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2007 |
Last Update Date | 27/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
40239 | MEDICAL LICENSE (01) | KY |
FH0471499 | DEA (01) | MI |