1770797151 NPI number — DR. MARISSA ANNE HENDRICKSON M.D.

Table of content: DR. MARISSA ANNE HENDRICKSON M.D. (NPI 1770797151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770797151 NPI number — DR. MARISSA ANNE HENDRICKSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKSON
Provider First Name:
MARISSA
Provider Middle Name:
ANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770797151
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 E RIVER PKWY
Provider Second Line Business Mailing Address:
PEDIATRIC EMERGENCY MEDICINE, 76 VCRC
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55455-0368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-625-6678
Provider Business Mailing Address Fax Number:
612-626-1144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 E RIVER PKWY
Provider Second Line Business Practice Location Address:
PEDIATRIC EMERGENCY MEDICINE, 76 VCRC
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55455-0368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-625-6678
Provider Business Practice Location Address Fax Number:
612-626-1144
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0204X , with the licence number:  50851 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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