Basic Information
| Provider Information | |||||||||
| NPI: | 1700851284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRICKSON-QUIRK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ALLISON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENDRICKSON | ||||||||
| OtherFirstName: | ALLISON | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1213 | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315211213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124667188 | ||||||||
| FaxNumber: | 9124667185 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 PARKWOOD DR | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315204722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124667188 | ||||||||
| FaxNumber: | 9124667185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 074434 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 074434 | GA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 115430406 | 05 | TX | MEDICAID | 003164419A | 05 | GA | MEDICAID | 115430404 | 05 | TX | MEDICAID | 115430405 | 05 | TX | MEDICAID |