Provider Demographics
NPI:1275642480
Name:EGNM LLC
Entity Type:Organization
Organization Name:EGNM LLC
Other - Org Name:LEWES SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:302-644-3311
Mailing Address - Street 1:17015 OLD ORCHARD ROAD
Mailing Address - Street 2:UNIT 4
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958
Mailing Address - Country:US
Mailing Address - Phone:302-644-3466
Mailing Address - Fax:302-258-0300
Practice Address - Street 1:17015 OLD ORCHARD ROAD
Practice Address - Street 2:UNIT 4
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958
Practice Address - Country:US
Practice Address - Phone:302-644-3466
Practice Address - Fax:302-258-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEFSSC-020261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000040711Medicaid
P00340586OtherRAILROAD MEDICARE
A00079Medicare PIN