Provider Demographics
NPI:1245381300
Name:FAMILY PRACTICE CENTER, PA
Entity Type:Organization
Organization Name:FAMILY PRACTICE CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:E
Authorized Official - Last Name:GROLL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-645-2833
Mailing Address - Street 1:34445 KING STREET ROW
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-4787
Mailing Address - Country:US
Mailing Address - Phone:302-645-2833
Mailing Address - Fax:302-644-4133
Practice Address - Street 1:34445 KING STREET ROW
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-4787
Practice Address - Country:US
Practice Address - Phone:302-645-2833
Practice Address - Fax:978-327-7891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001138402Medicaid