Basic Information
| Provider Information | |||||||||
| NPI: | 1659578425 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTIANA CARE HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CCHS GERIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HYGEIA DR | ||||||||
| Address2: | SUITE 2502 PHYSICIAN CONTRACTING CHRISTIANA CARE HEALTH | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026237362 | ||||||||
| FaxNumber: | 3026237374 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 N MARKET ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198024812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3024212700 | ||||||||
| FaxNumber: | 3024212705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | MCMURRAY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3024282522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHRISTIANA CARE HEALTH SERVICES INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207QG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1659578425 | 05 | DE | MEDICAID |