Provider Demographics
NPI:1134348527
Name:ELIAS MAMBERG MD PA
Entity type:Organization
Organization Name:ELIAS MAMBERG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELAIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-428-0337
Mailing Address - Street 1:1301 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-3128
Mailing Address - Country:US
Mailing Address - Phone:302-428-0337
Mailing Address - Fax:
Practice Address - Street 1:1301 NORTH HARRISON STREET
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806
Practice Address - Country:US
Practice Address - Phone:302-428-0337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE207V00000X302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000018501Medicaid
DE0000018501Medicaid