MEDICARE: DR. GRACE CHRISTINE HENDRICKSON DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	81503-21	WI
3	207K00000X	Allergy & Immunology Physician	81503-21	WI

General Provider Information

NPI Number	:	1174103097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRACE CHRISTINE HENDRICKSON DO

Provider Business Mailing Address
First Line	:	600 HIGHLAND AVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53792-0001
Country	:	US
Telephone Number	:	608-263-6400
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 HIGHLAND AVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53792-2664
Country	:	US
Telephone Number	:	608-263-6400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2021
Last Update Date	:	06/19/2024

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