Provider Demographics
NPI:1649311325
Name:NANTICOKE GASTROENTEROLOGY, P.A.
Entity type:Organization
Organization Name:NANTICOKE GASTROENTEROLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MACKLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-629-2229
Mailing Address - Street 1:924 MIDDLEFORD RD
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-3604
Mailing Address - Country:US
Mailing Address - Phone:302-629-2229
Mailing Address - Fax:302-629-2285
Practice Address - Street 1:924 MIDDLEFORD RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-3604
Practice Address - Country:US
Practice Address - Phone:302-629-2229
Practice Address - Fax:302-629-2285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10004336207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1939OtherCOVENTRY
DE0000825302Medicaid
DE421862OtherOPT CHOICE
MD0916029 00OtherMARYLAND MEDICAID
DE100010338OtherMEDICARE RAILROAD
DE2714OtherCAREFIRST
DE421862OtherMDIPA
DE505182OtherAETNA
DET266OtherBLUECROSS
DE085567809OtherCHAMPUS
DEPAL58270210001OtherCIGNA HEALTHCARE
DE2714OtherCAREFIRST
DE=========OtherCARELINK
DET266OtherBLUECROSS
DE100010338OtherMEDICARE RAILROAD