Provider Demographics
NPI:1861468522
Name:HENDRICKSON, TIMOTHY (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 NORTH ST
Mailing Address - Street 2:MGHA HOSPITALIST PROGRAM
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4974
Mailing Address - Country:US
Mailing Address - Phone:207-626-1018
Mailing Address - Fax:207-626-1214
Practice Address - Street 1:149 NORTH ST
Practice Address - Street 2:MGHA HOSPITALIST PROGRAM
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4974
Practice Address - Country:US
Practice Address - Phone:207-626-1018
Practice Address - Fax:207-872-1214
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME01573207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME310310099Medicaid
ME310310099Medicaid
MEG52574Medicare UPIN
ME110209328Medicare PIN