Provider Demographics
NPI:1396780664
Name:FENWICK MEDICAL CENTER PA
Entity type:Organization
Organization Name:FENWICK MEDICAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/EMPLOYER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:N
Authorized Official - Last Name:BORODULIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-539-2399
Mailing Address - Street 1:12036 S PINEY POINT RD
Mailing Address - Street 2:
Mailing Address - City:BISHOPVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21813-1542
Mailing Address - Country:US
Mailing Address - Phone:410-430-5154
Mailing Address - Fax:410-352-5430
Practice Address - Street 1:1400 COASTAL HWY
Practice Address - Street 2:
Practice Address - City:FENWICK ISLAND
Practice Address - State:DE
Practice Address - Zip Code:19944
Practice Address - Country:US
Practice Address - Phone:302-581-0458
Practice Address - Fax:302-581-0460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10001802261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEDG9614OtherRAILROAD MEDICARE
DEDG9614OtherRAILROAD MEDICARE
DE412338Medicare PIN
MD314PMedicare PIN