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General NPI Number Information
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NPI Number | 1154392850
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Entity Type | Individual
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Provider Name | ELISE MARIE HENRICKS MD
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Gender | Female
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Dates
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Enumeration Date | 01/30/2006
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Last Update Date | 01/09/2012
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Provider Practice Location Address
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Address Line | 415 COLUMBIA RD
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City | DORCHESTER
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State | MA
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Zip | 02125-2424
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Country | US
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Telephone | 617-740-8075
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Fax | 617-740-8060
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Provider Business Mailing Address
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Address Line | 415 COLUMBIA RD
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City | DORCHESTER
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State | MA
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Zip | 02125-2424
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Country | US
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Telephone | 617-740-8075
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Fax | 617-740-8060
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 156706
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License Number State | MA
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