Provider Demographics
NPI:1659798353
Name:DELAWARE INTEGRATIVE MEDICAL CENTER
Entity Type:Organization
Organization Name:DELAWARE INTEGRATIVE MEDICAL CENTER
Other - Org Name:DELAWARE INTEGRATIVE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:740-727-4686
Mailing Address - Street 1:20930 DUPONT BLVD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-1725
Mailing Address - Country:US
Mailing Address - Phone:302-258-8853
Mailing Address - Fax:
Practice Address - Street 1:20930 DUPONT BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-1725
Practice Address - Country:US
Practice Address - Phone:302-258-8853
Practice Address - Fax:302-253-8430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-20
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0009809207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty