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General NPI Number Information
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NPI Number | 1902056252
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Entity Type | Individual
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Provider Name | RONALD RUSSELL HENRICKSON MD
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Gender | Male
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Dates
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Enumeration Date | 09/23/2008
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Last Update Date | 09/23/2008
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Provider Practice Location Address
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Address Line | 32318 BISSON LN
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City | POLSON
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State | MT
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Zip | 59860-7354
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Country | US
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Telephone | 406-883-5723
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Fax |
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Provider Business Mailing Address
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Address Line | 32318 BISSON LN
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City | POLSON
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State | MT
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Zip | 59860-7354
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Country | US
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Telephone | 406-883-5723
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Fax |
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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 | 207YX0905X
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Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
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License Number | 4778
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License Number State | MT
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