Provider Demographics
NPI:1215336508
Name:MARK NEAL HENDRIXSON MD
Entity type:Organization
Organization Name:MARK NEAL HENDRIXSON MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRIXSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-456-8435
Mailing Address - Street 1:707 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-5011
Mailing Address - Country:US
Mailing Address - Phone:931-456-8435
Mailing Address - Fax:931-456-8496
Practice Address - Street 1:707 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-5011
Practice Address - Country:US
Practice Address - Phone:931-456-8435
Practice Address - Fax:931-456-8496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-22
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN021724174400000X
332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3091500Medicare PIN