Basic Information
| Provider Information | |||||||||
| NPI: | 1487616868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRICKS | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE G500 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911100 | ||||||||
| FaxNumber: | 3046911183 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE G500 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911100 | ||||||||
| FaxNumber: | 3046911183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 21808 | WV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 21808 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64098361 | 05 | KY | MEDICAID | 2558754 | 05 | OH | MEDICAID | 3810002242 | 05 | WV | MEDICAID |