Provider Demographics
NPI:1033187232
Name:HENRICKSON, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HENRICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:ML 4010
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3039
Mailing Address - Country:US
Mailing Address - Phone:513-636-4676
Mailing Address - Fax:513-636-5568
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 4010
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229
Practice Address - Country:US
Practice Address - Phone:513-636-4676
Practice Address - Fax:513-636-5568
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY460512080P0216X
OH35.0611052080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
24R600660Medicare PIN