1619174315 NPI number — DR. COURTNEY WILCZYNSKI D.O.

Table of content: DR. COURTNEY WILCZYNSKI D.O. (NPI 1619174315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619174315 NPI number — DR. COURTNEY WILCZYNSKI D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILCZYNSKI
Provider First Name:
COURTNEY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORRIN
Provider Other First Name:
COURTNEY
Provider Other Middle Name:
WILCZYNSKI
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619174315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
640 S. STATE STREET
Provider Second Line Business Mailing Address:
MAIL CODE 3055
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19901-3530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-480-1688
Provider Business Mailing Address Fax Number:
302-480-9807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 S. STATE STREET
Provider Second Line Business Practice Location Address:
BAYHEALTH EMERGENCY PHYSICIANS, ,LLC
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19901-3530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-744-6156
Provider Business Practice Location Address Fax Number:
302-735-3845
Provider Enumeration Date:
06/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  C2-0009374 , 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: 3621073 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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