=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922236942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAROL J HENDRICKSON DO PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2009
-----------------------------------------------------
Last Update Date | 07/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4669 12TH RD
-----------------------------------------------------
City | ESCANABA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49829-9605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-786-9391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4669 12TH RD
-----------------------------------------------------
City | ESCANABA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49829-9605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-786-9391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | MS. CYNTHIA R MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-207-5226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 5101012173
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------