Provider Demographics
NPI:1386662054
Name:SOUTHERN DELAWARE MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:SOUTHERN DELAWARE MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:SAMARY
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-725-2040
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-0337
Mailing Address - Country:US
Mailing Address - Phone:302-725-2040
Mailing Address - Fax:855-403-0778
Practice Address - Street 1:100 SILICATO PKWY STE 301
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1272
Practice Address - Country:US
Practice Address - Phone:302-725-2040
Practice Address - Fax:855-403-0778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC20006015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty