Provider Demographics
NPI:1790722478
Name:SPORTS MEDICINE OF DELAWARE, INC.
Entity Type:Organization
Organization Name:SPORTS MEDICINE OF DELAWARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:DISABELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:302-376-9711
Mailing Address - Street 1:102 SLEEPY HOLLOW DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-5841
Mailing Address - Country:US
Mailing Address - Phone:302-376-9711
Mailing Address - Fax:302-376-9713
Practice Address - Street 1:102 SLEEPY HOLLOW DR
Practice Address - Street 2:SUITE 102
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-8894
Practice Address - Country:US
Practice Address - Phone:302-376-9711
Practice Address - Fax:302-376-9713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0005338207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE2803109000OtherAMERIHEALTH
DE100040718Medicaid
DE2803109000OtherAMERIHEALTH
DE132210Medicare PIN