Provider Demographics
NPI:1952333130
Name:HENDRICKS, GLENNA P (MD)
Entity Type:Individual
Prefix:
First Name:GLENNA
Middle Name:P
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13540 HULL STREET RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2107
Mailing Address - Country:US
Mailing Address - Phone:804-739-6142
Mailing Address - Fax:804-739-8923
Practice Address - Street 1:13540 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2107
Practice Address - Country:US
Practice Address - Phone:804-739-6142
Practice Address - Fax:804-739-8923
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101229281207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010185475Medicaid
VA1001128OtherSENTARA
VA321012OtherSOUTHERN HEALTH SERVICES
VA3962989OtherAETNA HMO
VA4892804OtherCIGNA
VA5348291OtherCIGNA
VA7765699OtherAETNA LIFE
VA182433OtherANTHEM BCBS OF VA
VA2138657OtherMAMSI
VA010185475Medicaid
VA4892804OtherCIGNA
00W583B02Medicare ID - Type Unspecified