Provider Demographics
NPI:1013930510
Name:HENDRICKER, GARY I (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:I
Last Name:HENDRICKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:770-838-8563
Practice Address - Street 1:25 W LYON ST
Practice Address - Street 2:
Practice Address - City:TALLAPOOSA
Practice Address - State:GA
Practice Address - Zip Code:30176-1288
Practice Address - Country:US
Practice Address - Phone:770-824-2800
Practice Address - Fax:770-824-2810
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-06-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA029670207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C46065Medicare UPIN