Basic Information
| Provider Information | |||||||||
| NPI: | 1679514210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRICKSON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 11/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 032152 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2223 | 01 | MN | SIOUX VALLEY # | OTHER | 28232HE | 01 | MN | MNBS # | OTHER | MN1000020 | 01 | MN | LHS/BANNERHEALTH # | OTHER | 901108 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | 300793600 | 05 | MN | MEDICAID | 0106054 | 01 | MN | MEDICA # | OTHER | 10440 | 01 | MN | NDBS # | OTHER | 108034 | 01 | MN | UCARE # | OTHER | HP19489 | 01 | MN | HEALTHPARTNERS # | OTHER | 0106545 | 01 | MN | MEDICA # | OTHER | 16005 | 05 | MN | MEDICAID | DA9031015654 | 01 | MN | PREFERRED ONE # | OTHER |