Healthcare Provider Details

I. General information

NPI: 1881855930
Provider Name (Legal Business Name): BENJAMIN SIMON HENDRICKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N DUNLAP ST FL 2
MEMPHIS TN
38105-4625
US

IV. Provider business mailing address

850 POPLAR AVE BLDG 2
MEMPHIS TN
38105-4607
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-7337
  • Fax: 901-287-4646
Mailing address:
  • Phone: 901-287-7337
  • Fax: 901-287-4646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number70778
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35.126320
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number70778
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number56639
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: