Provider Demographics
NPI:1760874549
Name:SOUTHBRIDGE MEDICAL ADVISORY COUNCIL, INC.
Entity Type:Organization
Organization Name:SOUTHBRIDGE MEDICAL ADVISORY COUNCIL, INC.
Other - Org Name:HENRIETTA JOHNSON MEDICAL CENTER CLAYMONT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:NACHET
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:026-593-0773
Mailing Address - Street 1:2722 PHILADELPHIA PIKE
Mailing Address - Street 2:
Mailing Address - City:CLAYMONT
Mailing Address - State:DE
Mailing Address - Zip Code:19703-2568
Mailing Address - Country:US
Mailing Address - Phone:026-556-1873
Mailing Address - Fax:027-982-4733
Practice Address - Street 1:2722 PHILADELPHIA PIKE
Practice Address - Street 2:
Practice Address - City:CLAYMONT
Practice Address - State:DE
Practice Address - Zip Code:19703-2568
Practice Address - Country:US
Practice Address - Phone:302-655-6187
Practice Address - Fax:302-798-2473
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHBRIDGE MEDICAL ADVISORY COUNCIL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-03
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE440009OtherMEDICARE PROVIDER TRANSACTION ACCESS NUMBER