Provider Demographics
NPI:1861604076
Name:HIBERNIAN NEPHROLOGY GROUP
Entity type:Organization
Organization Name:HIBERNIAN NEPHROLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:N
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-628-1106
Mailing Address - Street 1:322 VALLEY ST NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-2912
Mailing Address - Country:US
Mailing Address - Phone:276-628-1106
Mailing Address - Fax:276-676-0215
Practice Address - Street 1:322 VALLEY ST NE
Practice Address - Street 2:SUITE A
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-2912
Practice Address - Country:US
Practice Address - Phone:276-628-1106
Practice Address - Fax:276-676-0215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048242174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09768Medicare ID - Type Unspecified