Healthcare Provider Details

I. General information

NPI: 1023224730
Provider Name (Legal Business Name): FIRST STATE PHYSICIANS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 FOX HUNT DR
BEAR DE
19701-2534
US

IV. Provider business mailing address

12 FOX HUNT DR
BEAR DE
19701-2534
US

V. Phone/Fax

Practice location:
  • Phone: 302-836-6150
  • Fax: 302-836-6294
Mailing address:
  • Phone: 302-836-6150
  • Fax: 302-836-6294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number2002101782
License Number StateDE

VIII. Authorized Official

Name: DR. KEVIN J MCDERMOTT
Title or Position: VICE-PRESIDENT
Credential: D.C.
Phone: 302-836-6150