Healthcare Provider Details

I. General information

NPI: 1992705610
Provider Name (Legal Business Name): JOHN C HENDRICKS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 SHELDON BLVD SE SUITE 100
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-6120
  • Fax: 616-391-6125
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001665
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: