1548301005 NPI number — SOUTHERN DELAWARE FOOT & ANKLE LLC

Table of content: (NPI 1548301005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548301005 NPI number — SOUTHERN DELAWARE FOOT & ANKLE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN DELAWARE FOOT & ANKLE LLC
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:
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:
1548301005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 772
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEAFORD
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19973-0772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-629-3613
Provider Business Mailing Address Fax Number:
302-629-2384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
543 N SHIPLEY ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SEAFORD
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19973-2339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-629-3000
Provider Business Practice Location Address Fax Number:
302-629-3080
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEMON
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
302-629-3000

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  E1-0000121 , 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: 8699345001 . This is a "CIGNA" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 448142 . This is a "OPTIMUM CHOICE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: P00062710 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2220599000 . This is a "AMERIHEALTH" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 3314440 . This is a "AETNA - PPO" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 1000025919 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2161 . This is a "COVENTRY" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 3316680 . This is a "AETNA - HMO" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 510401832 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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