Healthcare Provider Details

I. General information

NPI: 1811125073
Provider Name (Legal Business Name): STEPHEN M HENDRIKSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

IV. Provider business mailing address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

V. Phone/Fax

Practice location:
  • Phone: 401-737-7000
  • Fax: 401-736-4546
Mailing address:
  • Phone: 401-737-7000
  • Fax: 401-736-4546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD18464
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License NumberMD18464
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: