Healthcare Provider Details

I. General information

NPI: 1477640696
Provider Name (Legal Business Name): LAUREL MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 S CENTRAL AVE
LAUREL DE
19956-1418
US

IV. Provider business mailing address

66 RIVERS END DR
SEAFORD DE
19973-8011
US

V. Phone/Fax

Practice location:
  • Phone: 302-875-7753
  • Fax:
Mailing address:
  • Phone: 302-628-3018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC1-0005393
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberC1-0004999
License Number StateDE

VIII. Authorized Official

Name: ANTONIO PEDRO
Title or Position: CO-OWNER
Credential: M.D.
Phone: 302-875-7753