Healthcare Provider Details

I. General information

NPI: 1902890940
Provider Name (Legal Business Name): KAROL J HENDRICKSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAROL J HENDRICKSON D.O.

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E H ST
IRON MOUNTAIN MI
49801-4760
US

IV. Provider business mailing address

325 E H ST
IRON MOUNTAIN MI
49801-4760
US

V. Phone/Fax

Practice location:
  • Phone: 906-774-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101012173
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: