Basic Information
Provider Information | |||||||||
NPI: | 1356693394 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FIRST STATE INTERNAL MEDICINE PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1208 HURLOCK CT | ||||||||
Address2: |   | ||||||||
City: | BEAR | ||||||||
State: | DE | ||||||||
PostalCode: | 197014960 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3022612269 | ||||||||
FaxNumber: | 3028342184 | ||||||||
Practice Location | |||||||||
Address1: | 102 SLEEPY HOLLOW DR | ||||||||
Address2: | SUITE 101 | ||||||||
City: | MIDDLETOWN | ||||||||
State: | DE | ||||||||
PostalCode: | 197095841 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3022612269 | ||||||||
FaxNumber: | 3028342184 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/14/2012 | ||||||||
LastUpdateDate: | 02/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KHANDELWAL | ||||||||
AuthorizedOfficialFirstName: | RASHMI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3027538204 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 2012605820 | DE | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.