Provider Demographics
NPI:1154392850
Name:HENRICKS, ELISE MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:ELISE
Middle Name:MARIE
Last Name:HENRICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2424
Mailing Address - Country:US
Mailing Address - Phone:617-740-8075
Mailing Address - Fax:617-740-8060
Practice Address - Street 1:415 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-2424
Practice Address - Country:US
Practice Address - Phone:617-740-8075
Practice Address - Fax:617-740-8060
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA156706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
710514BMCOtherHARVARD PILGRIM
J19583OtherHMO BLUE
44447OtherAETNA/USHEALTHCARE
156706OtherTUFTS
MA3184846Medicaid
A28992Medicare ID - Type Unspecified
44447OtherAETNA/USHEALTHCARE