Healthcare Provider Details

I. General information

NPI: 1568976363
Provider Name (Legal Business Name): VINCENT B KILLEEN UTA RVOC TR OF CHARLES M MEENEHAN MD TTEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 SAVANNAH RD
LEWES DE
19958-1611
US

IV. Provider business mailing address

1535 SAVANNAH RD
LEWES DE
19958-1611
US

V. Phone/Fax

Practice location:
  • Phone: 302-645-4700
  • Fax: 302-645-6285
Mailing address:
  • Phone: 302-645-4700
  • Fax: 302-645-6285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number StateDE

VIII. Authorized Official

Name: LEO H ESCHBACH JR.
Title or Position: AUTHORIZED OFFICIAL
Credential: DO
Phone: 302-645-4700