1194927053 NPI number — AMY W ANZILOTTI MD

Table of content: AMY W ANZILOTTI MD (NPI 1194927053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194927053 NPI number — AMY W ANZILOTTI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANZILOTTI
Provider First Name:
AMY
Provider Middle Name:
W
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:
WAGNER
Provider Other First Name:
AMY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1194927053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 191
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLAND
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19723-0191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-651-6212
Provider Business Mailing Address Fax Number:
302-651-4945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 FOULK ROAD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19803-3157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-655-3242
Provider Business Practice Location Address Fax Number:
302-655-5392
Provider Enumeration Date:
06/04/2007

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: 208000000X , with the licence number:  C10007447 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208D00000X , with the licence number: C10007447 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0136247 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102040993 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 413092800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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