Healthcare Provider Details

I. General information

NPI: 1275642480
Provider Name (Legal Business Name): EGNM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17015 OLD ORCHARD ROAD UNIT 4
LEWES DE
19958
US

IV. Provider business mailing address

17015 OLD ORCHARD ROAD UNIT 4
LEWES DE
19958
US

V. Phone/Fax

Practice location:
  • Phone: 302-644-3466
  • Fax: 302-258-0300
Mailing address:
  • Phone: 302-644-3466
  • Fax: 302-258-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberFSSC-020
License Number StateDE

VIII. Authorized Official

Name: EDMUND THOMAS CARROLL III
Title or Position: OWNER/DIRECTOR
Credential: DO
Phone: 302-644-3311