Provider Demographics
NPI:1013004043
Name:HEMODIALYSIS ASSOC PC
Entity Type:Organization
Organization Name:HEMODIALYSIS ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:ENDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-861-9555
Mailing Address - Street 1:425 SANDHURST DR
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-7862
Mailing Address - Country:US
Mailing Address - Phone:804-861-9555
Mailing Address - Fax:804-861-9555
Practice Address - Street 1:3335 S CRATER RD
Practice Address - Street 2:
Practice Address - City:PETERSBURY
Practice Address - State:VA
Practice Address - Zip Code:23805
Practice Address - Country:US
Practice Address - Phone:804-862-5261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
005522OtherANTHEM BC/BS
VA8915229Medicaid
VAC00903Medicare PIN