Provider Demographics
NPI:1902901366
Name:HENDRICKSON, SUSAN COLLEEN (MD)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:COLLEEN
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2201
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48707-2201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48707-9801
Practice Address - Country:US
Practice Address - Phone:989-667-6977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060917208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3273870Medicaid
MI3273870Medicaid