1346605599 NPI number — OPTIMUM HEALTH GROUP INC

Table of content: (NPI 1346605599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346605599 NPI number — OPTIMUM HEALTH GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMUM HEALTH GROUP INC
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:
1346605599
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2323 PENNSYLVANIA AVE
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19806-1332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-225-9000
Provider Business Mailing Address Fax Number:
302-225-9005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2323 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-225-9000
Provider Business Practice Location Address Fax Number:
302-225-9005
Provider Enumeration Date:
12/15/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
Y.N.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
302-225-9000

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  F11000477 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: F1-0000477 , 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: 250026551 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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