Provider Demographics
NPI:1639417280
Name:SOUTHBRIDGE MEDICAL ADVISORY COUNCIL INC
Entity Type:Organization
Organization Name:SOUTHBRIDGE MEDICAL ADVISORY COUNCIL INC
Other - Org Name:HENRIETTA JOHNSON MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-427-9696
Mailing Address - Street 1:601 NEW CASTLE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19801-5821
Mailing Address - Country:US
Mailing Address - Phone:302-655-6187
Mailing Address - Fax:302-655-6606
Practice Address - Street 1:600 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-4429
Practice Address - Country:US
Practice Address - Phone:302-761-4610
Practice Address - Fax:302-655-6606
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHBRIDGE MEDICAL ADVISORY COUNCIL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No122300000XDental ProvidersDentistGroup - Multi-Specialty