Healthcare Provider Details

I. General information

NPI: 1528056629
Provider Name (Legal Business Name): FREDERIC CHARLES HENDRICKSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11550 STATE ROUTE 500
PAULDING OH
45879-9173
US

IV. Provider business mailing address

11550 STATE ROUTE 500
PAULDING OH
45879-9173
US

V. Phone/Fax

Practice location:
  • Phone: 419-399-2630
  • Fax: 419-782-8853
Mailing address:
  • Phone: 419-399-2630
  • Fax: 419-782-8853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-00-5455
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: