Provider Demographics
NPI:1962682849
Name:BRANDYWINE OBGYN, PA
Entity Type:Organization
Organization Name:BRANDYWINE OBGYN, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:COOKSEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:302-477-1375
Mailing Address - Street 1:3519 SILVERSIDE RD
Mailing Address - Street 2:SUITE 204 RIDGELY BLDG
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4909
Mailing Address - Country:US
Mailing Address - Phone:302-477-1375
Mailing Address - Fax:302-477-1383
Practice Address - Street 1:3519 SILVERSIDE RD
Practice Address - Street 2:SUITE 204 RIDGELY BLDG
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4909
Practice Address - Country:US
Practice Address - Phone:302-477-1375
Practice Address - Fax:302-477-1383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC20005691207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000013840Medicaid
00B237H16Medicare PIN
DE1000013840Medicaid
DEH31395Medicare UPIN