Provider Demographics
NPI:1295725711
Name:SOUTHERN DELAWARE SURGERY CENTER
Entity type:Organization
Organization Name:SOUTHERN DELAWARE SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTI
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN,CNOR,MHCA
Authorized Official - Phone:302-644-6992
Mailing Address - Street 1:18941 JOHN J WILLIAMS HWY
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-4404
Mailing Address - Country:US
Mailing Address - Phone:302-644-6992
Mailing Address - Fax:302-644-6995
Practice Address - Street 1:18941 JOHN J WILLIAMS HWY
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-4404
Practice Address - Country:US
Practice Address - Phone:302-644-6992
Practice Address - Fax:302-644-6995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEFSSC-012261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE165A61OtherBLUE CROSS BLUE SHIELD
DE1000034296Medicaid
DE1000034296Medicaid
DE08C0001020Medicare ID - Type UnspecifiedMEDICARE PROVIDER