Basic Information
Provider Information | |||||||||
NPI: | 1497851869 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ELSMERE FIRE COMPANY NO. 1 | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 71 OMEGA DR | ||||||||
Address2: | BUILDING D | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 197132063 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3022833300 | ||||||||
FaxNumber: | 3022833321 | ||||||||
Practice Location | |||||||||
Address1: | 1107 KIRKWOOD HWY | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | DE | ||||||||
PostalCode: | 198052117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3029990183 | ||||||||
FaxNumber: | 3029991721 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2006 | ||||||||
LastUpdateDate: | 08/20/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOWMAN | ||||||||
AuthorizedOfficialFirstName: | KEITH | ||||||||
AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
AuthorizedOfficialTitleorPosition: | REP | ||||||||
AuthorizedOfficialTelephone: | 3022833300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 3534 | DE | Y |   | Transportation Services | Ambulance |   |
ID Information
ID | Type | State | Issuer | Description | 0000541015 | 05 | DE |   | MEDICAID |