Provider Demographics
NPI:1194724799
Name:HENDRICKS, CHARLES W (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:C
Other - Middle Name:W
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8 RICHLAND MEDICAL PARK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-8005
Mailing Address - Country:US
Mailing Address - Phone:803-256-6511
Mailing Address - Fax:803-744-4731
Practice Address - Street 1:8 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 300
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8005
Practice Address - Country:US
Practice Address - Phone:803-256-6511
Practice Address - Fax:803-744-4731
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8093207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC80931Medicaid
SC8093OtherSC LICENSE
SCD47044Medicare UPIN