Provider Demographics
NPI:1740435650
Name:PETERSBURG DERMATOLOGY, PC
Entity type:Organization
Organization Name:PETERSBURG DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICK
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:FREIHOFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-861-5555
Mailing Address - Street 1:3277 S CRATER RD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9285
Mailing Address - Country:US
Mailing Address - Phone:804-861-5555
Mailing Address - Fax:804-861-5500
Practice Address - Street 1:3277 S CRATER RD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9285
Practice Address - Country:US
Practice Address - Phone:804-861-5555
Practice Address - Fax:804-861-5500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052210261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005900972Medicaid
G11418Medicare UPIN
VA005900972Medicaid