1730169186 NPI number — DR. SUSAN K HENDRICKS MD

Table of content: DR. SUSAN K HENDRICKS MD (NPI 1730169186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730169186 NPI number — DR. SUSAN K HENDRICKS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKS
Provider First Name:
SUSAN
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1730169186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
590 15TH ST S
Provider Second Line Business Mailing Address:
APT 145
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22202-2872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-418-0234
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
590 15TH ST S
Provider Second Line Business Practice Location Address:
APT 145
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22202-2872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-418-0234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/20/2006

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: 2080N0001X , with the licence number:  4201042151 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207VM0101X , with the licence number: 304262 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CA2184 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2433610 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4504927 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06979534 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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