Provider Demographics
NPI:1538241104
Name:HENDRICK, TINA R (MD)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:R
Last Name:HENDRICK
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-918-3400
Practice Address - Fax:812-335-7371
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059551207V00000X
KY56655207V00000X
IN01059551A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN090540768OtherMEDICARE PTAN
IN200945900AMedicaid
KY7100017830Medicaid
IN744915OtherAETNA
IN521891OtherANTHEM
KY50015141OtherKY PASSPORT