1891723540 NPI number — GAIL M WYNN MD

Table of content: GAIL M WYNN MD (NPI 1891723540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891723540 NPI number — GAIL M WYNN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYNN
Provider First Name:
GAIL
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1891723540
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
537 STANTON CHRISTIANA RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-2146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-892-9900
Provider Business Mailing Address Fax Number:
302-892-9980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
537 STANTON CHRISTIANA RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-2146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-892-9900
Provider Business Practice Location Address Fax Number:
302-892-9980
Provider Enumeration Date:
06/30/2006

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: 208600000X , with the licence number:  DE-C1-0005855 , 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: 179796 . This is a "COVENTRY" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2015899000 . This is a "PERSONAL CHOICE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 06-1641497 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2015899000 . This is a "AMERIHEALTH" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2015899000 . This is a "KEYSTONE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 0001097101 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2947383 . This is a "AETNA MANAGED CARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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