1265441331 NPI number — CENTRAL DELAWARE FAMILY MEDICINE PA

Table of content: (NPI 1265441331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265441331 NPI number — CENTRAL DELAWARE FAMILY MEDICINE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL DELAWARE FAMILY MEDICINE PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265441331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 S BRADFORD ST
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19904-4153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-735-1616
Provider Business Mailing Address Fax Number:
302-735-1617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 S BRADFORD ST
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19904-4153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-735-1616
Provider Business Practice Location Address Fax Number:
302-735-1617
Provider Enumeration Date:
08/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LITTLE
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
302-735-1616

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  2005202181 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CC8811 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 0000689602 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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