Provider Demographics
NPI:1114512068
Name:STATE OF DELAWARE
Entity Type:Organization
Organization Name:STATE OF DELAWARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AWELE
Authorized Official - Middle Name:N
Authorized Official - Last Name:MADUKA-EZEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-739-5601
Mailing Address - Street 1:245 MCKEE RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-2232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:660 BAYLOR BLVD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-1140
Practice Address - Country:US
Practice Address - Phone:302-577-3004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF DELAWARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health