Provider Demographics
NPI:1083741227
Name:CHRISTIANA MEDICAL GROUP
Entity Type:Organization
Organization Name:CHRISTIANA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:NANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTATELADZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-366-1868
Mailing Address - Street 1:4735 OGLETOWN STANTON RD
Mailing Address - Street 2:MAP-2, SUITE 2201
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2072
Mailing Address - Country:US
Mailing Address - Phone:302-366-1868
Mailing Address - Fax:302-366-8572
Practice Address - Street 1:4735 OGLETOWN STANTON RD
Practice Address - Street 2:MAP-2, SUITE 2201
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2072
Practice Address - Country:US
Practice Address - Phone:302-366-1868
Practice Address - Fax:302-366-8572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10008503208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC10008503OtherMEDICAL LICENSE