Provider Demographics
NPI:1275672677
Name:MID DELAWARE INTERNAL MEDICINE,PA
Entity Type:Organization
Organization Name:MID DELAWARE INTERNAL MEDICINE,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARRINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-674-9141
Mailing Address - Street 1:31 GOODEN AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-4143
Mailing Address - Country:US
Mailing Address - Phone:302-674-9141
Mailing Address - Fax:302-674-5907
Practice Address - Street 1:31 GOODEN AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4143
Practice Address - Country:US
Practice Address - Phone:302-674-9141
Practice Address - Fax:302-674-5907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0004573207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001085802Medicaid
DEG00327Medicare ID - Type UnspecifiedMEDICARE
DE0001085802Medicaid