Provider Demographics
NPI: | 1477623247 |
---|---|
Name: | HENRICKSON, KERRY H (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | KERRY |
Middle Name: | H |
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: | 975 PORT WASHINGTON RD |
Mailing Address - Street 2: | |
Mailing Address - City: | GRAFTON |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 53024-9201 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 262-329-1000 |
Mailing Address - Fax: | 262-329-1001 |
Practice Address - Street 1: | 975 PORT WASHINGTON RD |
Practice Address - Street 2: | |
Practice Address - City: | GRAFTON |
Practice Address - State: | WI |
Practice Address - Zip Code: | 53024-9201 |
Practice Address - Country: | US |
Practice Address - Phone: | 262-329-1000 |
Practice Address - Fax: | 262-329-1001 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-11-09 |
Last Update Date: | 2021-11-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WV | 25288 | 207R00000X |
WI | 25288 | 207RC0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WI | 31851900 | Medicaid | |
B53551 | Medicare UPIN | ||
WI | K400281860 | Medicare PIN |