Healthcare Provider Details

I. General information

NPI: 1114465812
Provider Name (Legal Business Name): FIRST STATE ORTHOPAEDICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SAVANNAH RD STE B
LEWES DE
19958-1550
US

IV. Provider business mailing address

211 EXECUTIVE DR STE 11
NEWARK DE
19702-3358
US

V. Phone/Fax

Practice location:
  • Phone: 302-645-2805
  • Fax: 302-645-1164
Mailing address:
  • Phone: 302-731-2888
  • Fax: 302-731-7049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberC10006103
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC10008726
License Number StateDE

VIII. Authorized Official

Name: ARLEEN A AUKAMP
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 302-451-6913