Healthcare Provider Details

I. General information

NPI: 1689227456
Provider Name (Legal Business Name): FIRST STATE ORTHOPAEDICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12100 BLACK SWAN DRIVE SUITE 101
LEWES DE
19958
US

IV. Provider business mailing address

211 EXECUTIVE DR STE 11
NEWARK DE
19702-3358
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID BLAEUER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 302-731-2888