Provider Demographics
NPI:1043468564
Name:C.A. HENDRICKS M.D. P.C.
Entity Type:Organization
Organization Name:C.A. HENDRICKS M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-362-9855
Mailing Address - Street 1:1136 H AVE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-4624
Mailing Address - Country:US
Mailing Address - Phone:319-362-9855
Mailing Address - Fax:319-362-0655
Practice Address - Street 1:1136 H AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-4624
Practice Address - Country:US
Practice Address - Phone:319-362-9855
Practice Address - Fax:319-362-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15724305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0029744Medicaid
181765472OtherRR MEDICARE
IA02974OtherBCBS
IA4501OtherMIDLANDS
IA0029744Medicaid
IA02974Medicare PIN