Provider Demographics
NPI:1447449012
Name:MARIAN HENDRICKS DO PA
Entity type:Organization
Organization Name:MARIAN HENDRICKS DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:361-985-1888
Mailing Address - Street 1:5833 SPOHN DR
Mailing Address - Street 2:SUITE601
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-4136
Mailing Address - Country:US
Mailing Address - Phone:361-985-1888
Mailing Address - Fax:361-985-0594
Practice Address - Street 1:5833 SPOHN DR
Practice Address - Street 2:SUITE 601
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-4136
Practice Address - Country:US
Practice Address - Phone:361-985-1888
Practice Address - Fax:361-985-0594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0089LBOtherBLUE CROSS BLUE SHIELD TX
TX165589601Medicaid
TX0089LBOtherBLUE CROSS BLUE SHIELD TX
TX165589601Medicaid