Provider Demographics
NPI:1912086018
Name:TRAUMA REHABILITATION , P.A.
Entity Type:Organization
Organization Name:TRAUMA REHABILITATION , P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:BOHDAN
Authorized Official - Last Name:BANDERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-777-7723
Mailing Address - Street 1:11B TROLLEY SQ
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-3342
Mailing Address - Country:US
Mailing Address - Phone:302-777-7723
Mailing Address - Fax:302-777-3454
Practice Address - Street 1:11B TROLLEY SQ
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-3342
Practice Address - Country:US
Practice Address - Phone:302-777-7723
Practice Address - Fax:302-777-3454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0003885208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000428601Medicaid
PA0012374630001Medicaid
DEBA725727Medicare ID - Type Unspecified
PA0012374630001Medicaid
PABA657400Medicare ID - Type Unspecified