Provider Demographics
NPI:1770658189
Name:STATE OF DELAWARE
Entity Type:Organization
Organization Name:STATE OF DELAWARE
Other - Org Name:MIDDLETOWN EPSDT
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:RATTAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-744-4700
Mailing Address - Street 1:417 FEDERAL ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-3635
Mailing Address - Country:US
Mailing Address - Phone:302-744-4548
Mailing Address - Fax:302-739-1613
Practice Address - Street 1:417 FEDERAL ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-3635
Practice Address - Country:US
Practice Address - Phone:302-744-4548
Practice Address - Fax:302-739-1613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000120349Medicaid