Provider Demographics
NPI:1104088863
Name:HENDRICKS, EDWARD CALE (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:CALE
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 S SERVICE RD
Mailing Address - Street 2:STE 350
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2354
Mailing Address - Country:US
Mailing Address - Phone:516-945-3107
Mailing Address - Fax:516-945-3131
Practice Address - Street 1:7519 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4178
Practice Address - Country:US
Practice Address - Phone:703-295-9360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101249184207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1104088863Medicaid
VA000641801Medicare PIN
VAP00975424Medicare PIN
VAVV1183AMedicare PIN
VA1183HMedicare PIN