Basic Information
Provider Information | |||||||||
NPI: | 1215040803 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENDEL | ||||||||
FirstName: | JERRY | ||||||||
MiddleName: | REED | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 712 S CASCADE ST | ||||||||
Address2: |   | ||||||||
City: | FERGUS FALLS | ||||||||
State: | MN | ||||||||
PostalCode: | 565372913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187368000 | ||||||||
FaxNumber: | 2187396718 | ||||||||
Practice Location | |||||||||
Address1: | 24 E 7TH ST | ||||||||
Address2: |   | ||||||||
City: | MORRIS | ||||||||
State: | MN | ||||||||
PostalCode: | 562671312 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3205894008 | ||||||||
FaxNumber: | 2187396718 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2006 | ||||||||
LastUpdateDate: | 02/17/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22506 | MN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1008789 | 01 | MN | PREFERRED ONE NUMBER | OTHER | 12222 | 05 | ND |   | MEDICAID | 49843HE | 01 | MN | BCBS NUMBER | OTHER | 123435 | 01 | MN | U-CARE NUMBER | OTHER | HP26572 | 01 | MN | HEALTHPARTNERS NUMBER | OTHER | 01-00798 | 01 | MN | MEDICA NUMBER FFMG | OTHER | 0967638 | 05 | IA |   | MEDICAID | 41091744413 | 05 | NE |   | MEDICAID | 336780100 | 05 | MN |   | MEDICAID |