Provider Demographics
NPI:1205823135
Name:HENDRICKSON, ROMAN MICHAEL SR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:MICHAEL
Last Name:HENDRICKSON
Suffix:SR
Gender:M
Credentials:MD
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:18 7M4R RD
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:MT
Mailing Address - Zip Code:59749-9500
Mailing Address - Country:US
Mailing Address - Phone:406-842-7581
Mailing Address - Fax:
Practice Address - Street 1:210 E CROFOOT ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:MT
Practice Address - Zip Code:59749
Practice Address - Country:US
Practice Address - Phone:406-842-5056
Practice Address - Fax:406-842-5057
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9867207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT00554470Medicaid
94575OtherBCBS
D57657Medicare UPIN
94575OtherBCBS