Provider Demographics
NPI:1508947482
Name:FIRST STATE DIAGNOSTIC CENTER, INC
Entity Type:Organization
Organization Name:FIRST STATE DIAGNOSTIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMAR
Authorized Official - Middle Name:TAYO
Authorized Official - Last Name:ADELEKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-777-1103
Mailing Address - Street 1:2401 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-1401
Mailing Address - Country:US
Mailing Address - Phone:302-777-1103
Mailing Address - Fax:302-777-1113
Practice Address - Street 1:2401 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-1401
Practice Address - Country:US
Practice Address - Phone:302-777-1103
Practice Address - Fax:302-777-1113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-00040052471N0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine TechnologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEG01311Medicare UPIN