Basic Information
| Provider Information | |||||||||
| NPI: | 1427536333 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTIANA SPINE CENTER PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHRISTIANA SPINE CENTER IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4735 OGLETOWN STANTON RD STE 3302 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026234144 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 TWIN C LN STE 101 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3029930280 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2018 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | MANGES | ||||||||
| AuthorizedOfficialFirstName: | VALERIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3029969522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHRISTIANA SPINE CENTER PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
No ID Information.