MEDICARE: JON R HENDRICKSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	N7630	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	52930	OTHER	AR	BLUE CROSS & BLUE SHIELD
2	17653000000	OTHER		QUALCHOICE
3	9718882	OTHER		CIGNA

General Provider Information

NPI Number	:	1447210448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON R HENDRICKSON MD

Provider Business Mailing Address
First Line	:	PO BOX 11017
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72917-1017
Country	:	US
Telephone Number	:	479-478-7200
Fax Number	:	478-478-7225

Provider Business Practice Location Address
First Line	:	7303 ROGERS AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-4112
Country	:	US
Telephone Number	:	479-478-7200
Fax Number	:	479-478-7225

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2006
Last Update Date	:	07/08/2007

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