1104980770 NPI number — MID-ATLANTIC PAIN INSTITUTE, P.A.

Table of content: (NPI 1104980770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104980770 NPI number — MID-ATLANTIC PAIN INSTITUTE, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-ATLANTIC PAIN INSTITUTE, P.A.
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:
6
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:
1104980770
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
139 E CHESTNUT HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-4043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-369-1700
Provider Business Mailing Address Fax Number:
302-369-1717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1806 N VAN BUREN ST
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19802-3851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-472-0163
Provider Business Practice Location Address Fax Number:
302-472-0164
Provider Enumeration Date:
12/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FALCO
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
302-369-1700

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  C10004539 , 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: 001097202 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: CF8249 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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