Provider Demographics
NPI:1104852300
Name:DELAWARE PRIMARY CARE LLC
Entity Type:Organization
Organization Name:DELAWARE PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DEPARTMENT
Authorized Official - Prefix:
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:T
Authorized Official - Last Name:PATRICKCOOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-730-0554
Mailing Address - Street 1:810 NEW BURTON RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-5451
Mailing Address - Country:US
Mailing Address - Phone:302-730-0554
Mailing Address - Fax:302-730-1175
Practice Address - Street 1:810 NEW BURTON RD
Practice Address - Street 2:SUITE 3
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-5451
Practice Address - Country:US
Practice Address - Phone:302-730-0554
Practice Address - Fax:302-730-1175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005391207R00000X
DEC10005294207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DECK3544OtherPALMETTO GBA
DE0001165602Medicaid
DE0001165602Medicaid
DE0001165602Medicaid