Healthcare Provider Details

I. General information

NPI: 1750381935
Provider Name (Legal Business Name): JOHN C HENDRICKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOHN C HENDRICKS M.D. S.C.

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date: 03/22/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

2701 17TH ST
ROCK ISLAND IL
61201-5351
US

IV. Provider business mailing address

PO BOX 689
LAKE FOREST IL
60045-0689
US

V. Phone/Fax

Practice location:
  • Phone: 309-779-5000
  • Fax:
Mailing address:
  • Phone: 847-615-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD-30791
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036076685
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: