Provider Demographics
NPI:1992870190
Name:EDWIN P HENDRICKS, JR. DO
Entity type:Organization
Organization Name:EDWIN P HENDRICKS, JR. DO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKS, JR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:706-778-3259
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-0669
Mailing Address - Country:US
Mailing Address - Phone:706-778-3259
Mailing Address - Fax:706-776-8660
Practice Address - Street 1:4020 DEMOREST MOUNT AIRY HWY
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-5003
Practice Address - Country:US
Practice Address - Phone:706-778-3259
Practice Address - Fax:706-776-8660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1550Medicare ID - Type UnspecifiedGROUP NUMBER