Provider Demographics
NPI:1306827639
Name:HENDRICKS, MARK VINING (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:VINING
Last Name:HENDRICKS
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 1:840 PINE STREET
Mailing Address - Street 2:SUITE 780
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-744-2445
Mailing Address - Fax:478-744-0906
Practice Address - Street 1:840 PINE STREET
Practice Address - Street 2:SUITE 780
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-744-2445
Practice Address - Fax:478-744-0906
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043061207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000904219AMedicaid
GA290013678OtherMEDICARE RAILROAD
GAH46981Medicare UPIN
GA11BDS2VMedicare PIN
GA000904219AMedicaid