1790722478 NPI number — SPORTS MEDICINE OF DELAWARE, INC.

Table of content: (NPI 1790722478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790722478 NPI number — SPORTS MEDICINE OF DELAWARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS MEDICINE OF DELAWARE, 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:
1790722478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 SLEEPY HOLLOW DR
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19709-5841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-376-9711
Provider Business Mailing Address Fax Number:
302-376-9713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 SLEEPY HOLLOW DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19709-8894
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-376-9711
Provider Business Practice Location Address Fax Number:
302-376-9713
Provider Enumeration Date:
06/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DISABELLA
Authorized Official First Name:
VINCENT
Authorized Official Middle Name:
NEIL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
302-376-9711

Provider Taxonomy Codes

  • Taxonomy code: 207RS0010X , with the licence number:  C2-0005338 , 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: 2803109000 . This is a "AMERIHEALTH" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 100040718 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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