Healthcare Provider Details

I. General information

NPI: 1487616868
Provider Name (Legal Business Name): GREGORY S HENDRICKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 MEDICAL CENTER DR SUITE G500
HUNTINGTON WV
25701-3656
US

IV. Provider business mailing address

1600 MEDICAL CENTER DR SUITE G500
HUNTINGTON WV
25701-3656
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-1100
  • Fax: 304-691-1183
Mailing address:
  • Phone: 304-691-1100
  • Fax: 304-691-1183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21808
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number21808
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: