Provider Demographics
NPI:1578608592
Name:DELAWARE MODERN PEDIATRICS
Entity Type:Organization
Organization Name:DELAWARE MODERN PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MACOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-392-2067
Mailing Address - Street 1:300 BIDDLE AVE
Mailing Address - Street 2:CONNOR BUILDING SUITE 206
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-3969
Mailing Address - Country:US
Mailing Address - Phone:302-392-2067
Mailing Address - Fax:302-228-8168
Practice Address - Street 1:300 BIDDLE AVE
Practice Address - Street 2:CONNOR BUILDING SUITE 206
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-3969
Practice Address - Country:US
Practice Address - Phone:302-392-2067
Practice Address - Fax:302-228-8168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE2007214283208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty