Healthcare Provider Details

I. General information

NPI: 1245209477
Provider Name (Legal Business Name): JOEL H. HENDRICKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 NININGER RD
HASTINGS MN
55033-1056
US

IV. Provider business mailing address

1175 NININGER RD
HASTINGS MN
55033-1056
US

V. Phone/Fax

Practice location:
  • Phone: 651-480-4100
  • Fax:
Mailing address:
  • Phone: 651-480-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25992
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: