Basic Information
| Provider Information | |||||||||
| NPI: | 1821059387 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTIANA SPINE CENTER PA | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PHYSIATRISTS ASSOCIATES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4735 OGLETOWN STANTON RD | ||||||||
| Address2: | SUITE 3302 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026234144 | ||||||||
| FaxNumber: | 3026234147 | ||||||||
| Practice Location | |||||||||
| Address1: | 4735 OGLETOWN STANTON RD STE 3302 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026234144 | ||||||||
| FaxNumber: | 3026234147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 09/25/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MANGES | ||||||||
| AuthorizedOfficialFirstName: | VALERIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3029969522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0078028000 | 01 | DE | AMERIHEALTH | OTHER | 0000135302 | 05 | DE | MEDICAID | 93388 | 01 | DE | AETNA | OTHER | CL3148 | 01 | RAILROAD MCR | OTHER | 25305 | 01 | DE | UNITED HC | OTHER |