MEDICARE: BRIAN L HENDRICKSON D.O.

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	207R00000X	Internal Medicine Physician	34006558	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710961412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN L HENDRICKSON D.O.

Provider Business Mailing Address
First Line	:	1153 E MAIN ST
Second Line	:	PO BOX 2563
City	:	LANCASTER
State	:	OH
Zip	:	43130-4056
Country	:	US
Telephone Number	:	740-687-8990
Fax Number	:	740-687-8230

Provider Business Practice Location Address
First Line	:	2405 N COLUMBUS ST
Second Line	:	SUITE 280
City	:	LANCASTER
State	:	OH
Zip	:	43130-8185
Country	:	US
Telephone Number	:	740-689-4470
Fax Number	:	740-808-8157

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

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	10/05/2016

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