=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902901366
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN COLLEEN HENDRICKSON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 02/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 WASHINGTON AVE
-----------------------------------------------------
City | BAY CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48707-9801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-667-6977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2201
-----------------------------------------------------
City | BAY CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48707-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 4301060917
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------