Provider Demographics
NPI:1225173149
Name:GEORGETOWN FAMILY MEDICINE
Entity Type:Organization
Organization Name:GEORGETOWN FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:SCOT
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-856-3171
Mailing Address - Street 1:201 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-1440
Mailing Address - Country:US
Mailing Address - Phone:302-856-3171
Mailing Address - Fax:302-856-2330
Practice Address - Street 1:201 W MARKET ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-1440
Practice Address - Country:US
Practice Address - Phone:302-856-3171
Practice Address - Fax:302-856-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0006044207Q00000X
DEC2-0006045207Q00000X
DEC5-00000702363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001044304Medicaid
DEG00438OtherPETAN
DE=========OtherTAX