Basic Information
| Provider Information | |||||||||
| NPI: | 1396961322 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENDRICK PROVIDER NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1198 | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796041198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256704220 | ||||||||
| FaxNumber: | 3256728292 | ||||||||
| Practice Location | |||||||||
| Address1: | 1904 PINE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796012344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256704220 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 03/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | PEARSON | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP REGIONAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3256707106 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RH0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RS0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080866901 | 05 | TX | MEDICAID | 0060AE | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |