Provider Demographics
NPI:1043329147
Name:HENDRICKS, KELLY J (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5701 W 119TH ST STE 410
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-3721
Mailing Address - Country:US
Mailing Address - Phone:913-345-6901
Mailing Address - Fax:913-469-4095
Practice Address - Street 1:5701 W 119TH ST STE 410
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-3721
Practice Address - Country:US
Practice Address - Phone:913-345-6901
Practice Address - Fax:913-469-4095
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-30708207X00000X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200265840AMedicaid
MO34266011OtherBCBS
KS580580OtherFIRSTGUARD
MO209281302Medicaid
P00154501OtherRAILROAD MEDICARE
P00154501OtherRAILROAD MEDICARE
009D263AMedicare ID - Type UnspecifiedMEDICARE