Provider Demographics
NPI:1356521504
Name:SOUTHEAST IOWA ORTHOPEDICS & SPORTS MEDICINE PC
Entity type:Organization
Organization Name:SOUTHEAST IOWA ORTHOPEDICS & SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-758-9133
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-0156
Mailing Address - Country:US
Mailing Address - Phone:319-758-9133
Mailing Address - Fax:319-758-9143
Practice Address - Street 1:903 OAK ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-4608
Practice Address - Country:US
Practice Address - Phone:319-758-9133
Practice Address - Fax:319-758-9143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26178174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA10954OtherMIDLANDS CHOICE
IA30001OtherIAHS
470000991OtherMEDICARE RAILROAD
IA267960871OtherMEDICAID ILLINOIS
IA1043539Medicaid
IA46204OtherBCBS
IA267960871OtherMEDICAID ILLINOIS
470000991OtherMEDICARE RAILROAD