Basic Information
| Provider Information | |||||||||
| NPI: | 1275774747 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTIANA SPINE AMBULATORY SURGICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4735 OGLETOWN STANTON RD | ||||||||
| Address2: | SUITE 3302 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026234144 | ||||||||
| FaxNumber: | 3026234147 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 TWIN C LANE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026234144 | ||||||||
| FaxNumber: | 3026234147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2009 | ||||||||
| LastUpdateDate: | 07/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | CUCUZZELLA | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3026234144 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | PENDING | DE | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1457480535 | 01 | DE | NPI # | OTHER |