Provider Demographics
NPI:1477640696
Name:LAUREL MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:LAUREL MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-875-7753
Mailing Address - Street 1:66 RIVERS END DR
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-8011
Mailing Address - Country:US
Mailing Address - Phone:302-628-3018
Mailing Address - Fax:
Practice Address - Street 1:1124 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:DE
Practice Address - Zip Code:19956-1418
Practice Address - Country:US
Practice Address - Phone:302-875-7753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0005393207R00000X
DEC1-0004999207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty