Healthcare Provider Details

I. General information

NPI: 1780002261
Provider Name (Legal Business Name): JOHN MICHAEL HENDRICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E RM 4C104
SALT LAKE CITY UT
84132-0002
US

IV. Provider business mailing address

30 N 1900 E RM 4C104
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-581-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number9560104-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number9560104-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: