Healthcare Provider Details

I. General information

NPI: 1053450981
Provider Name (Legal Business Name): ADOLESCENT MEDICINE GENERAL PEDIATRICS & ALLERGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

863 BUTTNER PLACE SUITE 103
DOVER DE
19904-2406
US

IV. Provider business mailing address

863 BUTTNER PLACE SUITE 103
DOVER DE
19904-2406
US

V. Phone/Fax

Practice location:
  • Phone: 302-734-3331
  • Fax: 302-734-9908
Mailing address:
  • Phone: 302-734-3331
  • Fax: 302-734-9908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FIZUL H BACCHUS
Title or Position: OWNER
Credential: DO
Phone: 302-734-3331