Provider Demographics
NPI:1861583510
Name:FREDERICKSBURG NEPHROLOGY ASSOCIATES, INC.
Entity type:Organization
Organization Name:FREDERICKSBURG NEPHROLOGY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVENCHER
Authorized Official - Suffix:
Authorized Official - Credentials:PROVENCHER
Authorized Official - Phone:540-371-3010
Mailing Address - Street 1:101 PARK HILL DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-3357
Mailing Address - Country:US
Mailing Address - Phone:540-371-3010
Mailing Address - Fax:540-899-9821
Practice Address - Street 1:101 PARK HILL DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3357
Practice Address - Country:US
Practice Address - Phone:540-371-3010
Practice Address - Fax:540-899-9821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02992Medicare PIN