Provider Demographics
NPI:1710007430
Name:ENDE MEDICAL PRACTICE, LLP
Entity Type:Organization
Organization Name:ENDE MEDICAL PRACTICE, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:EADS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:804-733-8909
Mailing Address - Street 1:121 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-4217
Mailing Address - Country:US
Mailing Address - Phone:804-733-8771
Mailing Address - Fax:804-733-1017
Practice Address - Street 1:121 S MARKET ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4217
Practice Address - Country:US
Practice Address - Phone:804-733-8771
Practice Address - Fax:804-733-1017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC07014Medicare ID - Type Unspecified