1578608592 NPI number — DELAWARE MODERN PEDIATRICS

Table of content: (NPI 1578608592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578608592 NPI number — DELAWARE MODERN PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELAWARE MODERN PEDIATRICS
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:
1578608592
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 BIDDLE AVE
Provider Second Line Business Mailing Address:
CONNOR BUILDING SUITE 206
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19702-3969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-392-2067
Provider Business Mailing Address Fax Number:
302-228-8168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 BIDDLE AVE
Provider Second Line Business Practice Location Address:
CONNOR BUILDING SUITE 206
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19702-3969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-392-2067
Provider Business Practice Location Address Fax Number:
302-228-8168
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MACOLLEY
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
302-392-2067

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  2007214283 , 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)





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