Provider Demographics
NPI:1508048745
Name:HEAL MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:HEAL MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AYOOLA
Authorized Official - Middle Name:AYOBANJI
Authorized Official - Last Name:AYOOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-741-0204
Mailing Address - Street 1:200 BANNING ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-3485
Mailing Address - Country:US
Mailing Address - Phone:302-367-5808
Mailing Address - Fax:302-674-5874
Practice Address - Street 1:200 BANNING ST
Practice Address - Street 2:SUITE #300
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3485
Practice Address - Country:US
Practice Address - Phone:302-741-0204
Practice Address - Fax:302-674-5874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0007939207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE100041565Medicaid
DEI60987Medicare UPIN
DE100041565Medicaid
DE492136Medicare PIN