Provider Demographics
NPI:1700851284
Name:HENDRICKSON-QUIRK, MARY ALLISON (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALLISON
Last Name:HENDRICKSON-QUIRK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:
Other - Last Name:HENDRICKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 1213
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31521-1213
Mailing Address - Country:US
Mailing Address - Phone:912-466-7188
Mailing Address - Fax:912-466-7185
Practice Address - Street 1:2415 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4722
Practice Address - Country:US
Practice Address - Phone:912-466-7188
Practice Address - Fax:912-466-7185
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA074434207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115430406Medicaid
GA003164419AMedicaid
TX115430404Medicaid
TX115430405Medicaid
752824993OtherTAX ID NUMBER
TX8K9089Medicare PIN
752824993OtherTAX ID NUMBER
TX115430405Medicaid