Basic Information
| Provider Information | |||||||||
| NPI: | 1104850510 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENDRICKS CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 E LINCOLN ST | ||||||||
| Address2: | PO BOX 26 | ||||||||
| City: | HENDRICKS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561360026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072753121 | ||||||||
| FaxNumber: | 5072753194 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 E LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | HENDRICKS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561360026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072753121 | ||||||||
| FaxNumber: | 5072753194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 12/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | MCCLUSKEY | ||||||||
| AuthorizedOfficialFirstName: | TABB | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5072753121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 1757969 | MN | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 232816000 | 05 | MN | MEDICAID |