Provider Demographics
NPI:1821172834
Name:FIRST STATE FAMILY PRACTICE, INC
Entity Type:Organization
Organization Name:FIRST STATE FAMILY PRACTICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEHAGIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-378-5494
Mailing Address - Street 1:222 CARTER DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-5854
Mailing Address - Country:US
Mailing Address - Phone:302-378-5494
Mailing Address - Fax:302-378-1760
Practice Address - Street 1:222 CARTER DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-5854
Practice Address - Country:US
Practice Address - Phone:302-378-5494
Practice Address - Fax:302-378-1760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10006722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000021662Medicaid
DE080195041OtherRAILROAD MEDICARE
DE2148253000OtherAMERIHEALTH HMO
DE1000021662OtherDPCI
DE1463747OtherAMERIHEALTH PPO
DE3157375OtherAETNA
DE1000021662OtherDPCI
DE=========OtherCOVENTRY
DE1000021662Medicaid
DE3157375OtherAETNA
DE=========OtherCOVENTRY
DE1000021662Medicaid