Healthcare Provider Details

I. General information

NPI: 1902056252
Provider Name (Legal Business Name): RONALD RUSSELL HENRICKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32318 BISSON LN
POLSON MT
59860-7354
US

IV. Provider business mailing address

32318 BISSON LN
POLSON MT
59860-7354
US

V. Phone/Fax

Practice location:
  • Phone: 406-883-5723
  • Fax:
Mailing address:
  • Phone: 406-883-5723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number4778
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: