Provider Demographics
NPI:1487628673
Name:EDEN HILL SURGICAL GROUP
Entity Type:Organization
Organization Name:EDEN HILL SURGICAL GROUP
Other - Org Name:GLENN & DOMENICK, MD, PA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDT
Authorized Official - Middle Name:J
Authorized Official - Last Name:FEUERSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-735-8850
Mailing Address - Street 1:200 BANNING ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-3485
Mailing Address - Country:US
Mailing Address - Phone:302-735-8850
Mailing Address - Fax:302-735-8851
Practice Address - Street 1:200 BANNING ST
Practice Address - Street 2:SUITE 310
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3485
Practice Address - Country:US
Practice Address - Phone:302-735-8850
Practice Address - Fax:302-735-8851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0003052174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000891702Medicaid
DEG00937Medicare PIN