Provider Demographics
NPI:1801943824
Name:BRANDYWINE PAIN MANAGEMENT P A
Entity type:Organization
Organization Name:BRANDYWINE PAIN MANAGEMENT P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PRAMOD
Authorized Official - Middle Name:K
Authorized Official - Last Name:YADHATI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-998-2585
Mailing Address - Street 1:PO BOX 3012
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804-0012
Mailing Address - Country:US
Mailing Address - Phone:302-224-5678
Mailing Address - Fax:302-224-2848
Practice Address - Street 1:4512 KIRKWOOD HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5123
Practice Address - Country:US
Practice Address - Phone:302-998-2585
Practice Address - Fax:302-998-3394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001186102Medicaid
DE0001186102Medicaid