Provider Demographics
NPI:1720172885
Name:DELAWARE WOMENS IMAGING LLC
Entity Type:Organization
Organization Name:DELAWARE WOMENS IMAGING LLC
Other - Org Name:WOMENS IMAGING CENTER OF DELAWARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MS
Authorized Official - Phone:302-993-2330
Mailing Address - Street 1:1601 MILLTOWN RD
Mailing Address - Street 2:SUITE 13
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-4027
Mailing Address - Country:US
Mailing Address - Phone:302-993-2330
Mailing Address - Fax:302-993-2344
Practice Address - Street 1:J-24 OMEGA DRIVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713
Practice Address - Country:US
Practice Address - Phone:302-738-9100
Practice Address - Fax:302-739-9748
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIA PRACTICE ENTERPRISES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-03
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE20066024882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000632802Medicaid
DE2006602488OtherLICENSE NUMBER
DE0000632802Medicaid