Healthcare Provider Details

I. General information

NPI: 1902901366
Provider Name (Legal Business Name): SUSAN COLLEEN HENDRICKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WASHINGTON AVE
BAY CITY MI
48707-9801
US

IV. Provider business mailing address

PO BOX 2201
BAY CITY MI
48707-2201
US

V. Phone/Fax

Practice location:
  • Phone: 989-667-6977
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301060917
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: