Basic Information
Provider Information | |||||||||
NPI: | 1669631909 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ERENA | ||||||||
FirstName: | ENDALKACHEW | ||||||||
MiddleName: | G.MICHAEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4469 S FOUR MILE RUN DR | ||||||||
Address2: |   | ||||||||
City: | ARLINGTON | ||||||||
State: | VA | ||||||||
PostalCode: | 222043501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7035210490 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5801 BREMO ROAD | ||||||||
Address2: | 2041 GEORGIA AVE NW | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232261907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8012850620 | ||||||||
FaxNumber: | 8042850726 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2008 | ||||||||
LastUpdateDate: | 07/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101247789 | VA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 0101247789 | VA | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
No ID Information.