Provider Demographics
NPI:1508823865
Name:DELINE, CONSTANCE ROSE (MD)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:ROSE
Last Name:DELINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 PRINCE ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-3113
Mailing Address - Country:US
Mailing Address - Phone:717-545-1717
Mailing Address - Fax:717-737-8062
Practice Address - Street 1:49 PRINCE ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-3113
Practice Address - Country:US
Practice Address - Phone:717-545-1717
Practice Address - Fax:717-737-8062
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065431L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G46346Medicare UPIN
PA021479Medicare ID - Type Unspecified