Healthcare Provider Details

I. General information

NPI: 1013930510
Provider Name (Legal Business Name): GARY I HENDRICKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W LYON ST
TALLAPOOSA GA
30176-1288
US

IV. Provider business mailing address

119 AMBULANCE DR SUITE 202
CARROLLTON GA
30117-3857
US

V. Phone/Fax

Practice location:
  • Phone: 770-824-2800
  • Fax: 770-824-2810
Mailing address:
  • Phone: 770-838-8710
  • Fax: 770-838-8563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number029670
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: