Provider Demographics
NPI:1750381935
Name:HENDRICKS, JOHN C (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:C
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD SC
Mailing Address - Street 1:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-0689
Mailing Address - Country:US
Mailing Address - Phone:847-615-2200
Mailing Address - Fax:
Practice Address - Street 1:2701 17TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5351
Practice Address - Country:US
Practice Address - Phone:309-779-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2024-05-23
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
IAMD-30791207L00000X
IL036076685207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076685Medicaid
IA0990986Medicaid
IAI8250Medicare PIN
IA0990986Medicaid
IL214801Medicare PIN
C64759Medicare UPIN