1821172834 NPI number — FIRST STATE FAMILY PRACTICE, INC

Table of content: (NPI 1821172834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821172834 NPI number — FIRST STATE FAMILY PRACTICE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRST STATE FAMILY PRACTICE, 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:
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:
1821172834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 CARTER DR
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19709-5854
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-378-5494
Provider Business Mailing Address Fax Number:
302-378-1760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 CARTER DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19709-5854
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-378-5494
Provider Business Practice Location Address Fax Number:
302-378-1760
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KEHAGIAS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
302-378-5494

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  C10006722 , 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: 1000021662 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080195041 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2148253000 . This is a "AMERIHEALTH HMO" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 1000021662 . This is a "DPCI" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 1463747 . This is a "AMERIHEALTH PPO" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 3157375 . This is a "AETNA" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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