Provider Demographics
NPI:1902890940
Name:HENDRICKSON, KAROL J (DO)
Entity Type:Individual
Prefix:MS
First Name:KAROL
Middle Name:J
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MS
Other - First Name:KAROL
Other - Middle Name:J
Other - Last Name:HENDRICKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:325 E H ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-4760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 E H ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4760
Practice Address - Country:US
Practice Address - Phone:906-774-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012173207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4508229Medicaid
F88104Medicare UPIN
OM30920014Medicare ID - Type Unspecified
MI4508229Medicaid