Provider Demographics
NPI:1588615223
Name:MA HENDRICKSON DO PA
Entity Type:Organization
Organization Name:MA HENDRICKSON DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:M
Authorized Official - Middle Name:ALLISON
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-284-4081
Mailing Address - Street 1:4109 CAGLE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-8339
Mailing Address - Country:US
Mailing Address - Phone:817-284-4081
Mailing Address - Fax:817-284-3988
Practice Address - Street 1:4109 CAGLE DR
Practice Address - Street 2:SUITE B
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-8339
Practice Address - Country:US
Practice Address - Phone:817-284-4081
Practice Address - Fax:817-284-3988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0064MAOtherBCBS GROUP NUMBER
110208679OtherMEDICARE RR GROUP NUMBER
TX172016101Medicaid
TX172016101Medicaid