Basic Information
| Provider Information | |||||||||
| NPI: | 1477063386 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORELIFE OF DELMARVA LLC | ||||||||
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| OtherOrganizationName: | CORELIFE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 BENFIELD BLVD STE 250 | ||||||||
| Address2: | |||||||||
| City: | MILLERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211083005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436794309 | ||||||||
| FaxNumber: | 8557724748 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E VINE ST STE B | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218045531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4433586239 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2017 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| AuthorizedOfficialLastName: | KOSTKOWSKI | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4436794309 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.