Healthcare Provider Details

I. General information

NPI: 1376700435
Provider Name (Legal Business Name): JUDITH A. HENDRICKS, M.D. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 RICHMOND RD
STATEN ISLAND NY
10306-2553
US

IV. Provider business mailing address

1870 RICHMOND RD
STATEN ISLAND NY
10306-2553
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-5400
  • Fax: 718-980-6012
Mailing address:
  • Phone: 718-667-5400
  • Fax: 718-980-6012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number127469
License Number StateNY

VIII. Authorized Official

Name: JUDITH A. HENDRICKS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 718-667-5400