Provider Demographics
NPI:1912016155
Name:BRANDYWINE PEDIATRICS, P.A.
Entity Type:Organization
Organization Name:BRANDYWINE PEDIATRICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ILENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-479-0294
Mailing Address - Street 1:3521 SILVERSIDE RD
Mailing Address - Street 2:1F QUILLEN BLDG
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4900
Mailing Address - Country:US
Mailing Address - Phone:302-479-0294
Mailing Address - Fax:302-478-2637
Practice Address - Street 1:3521 SILVERSIDE RD
Practice Address - Street 2:1F QUILLEN BLDG
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4900
Practice Address - Country:US
Practice Address - Phone:302-479-0294
Practice Address - Fax:302-478-2637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000684202Medicaid