Provider Demographics
NPI:1477007797
Name:MID-ATLANTIC SURGICAL PRACTICE
Entity Type:Organization
Organization Name:MID-ATLANTIC SURGICAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAN
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:TAYOUN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:302-652-6050
Mailing Address - Street 1:PO BOX 8157
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-8157
Mailing Address - Country:US
Mailing Address - Phone:302-652-6050
Mailing Address - Fax:302-652-6053
Practice Address - Street 1:1500 SHALLCROSS AVE
Practice Address - Street 2:SUITE 1-A
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-3037
Practice Address - Country:US
Practice Address - Phone:302-652-6050
Practice Address - Fax:302-652-6053
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-ATLANTIC SURGICAL PRACTICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-04
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000035769Medicaid