Basic Information
| Provider Information | |||||||||
| NPI: | 1679539928 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDREN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | CONLEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 BURTON HILLS BLVD | ||||||||
| Address2: | STE 175 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159882014 | ||||||||
| FaxNumber: | 6155230647 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 N EL PASO AVE | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728013737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799684177 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 08/31/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C-5062 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 101738001 | 05 | AR | MEDICAID |