Healthcare Provider Details

I. General information

NPI: 1891048179
Provider Name (Legal Business Name): REGIONAL MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4512 KIRKWOOD HWY STE 202
WILMINGTON DE
19808-5123
US

IV. Provider business mailing address

4512 KIRKWOOD HWY STE 202
WILMINGTON DE
19808-5122
US

V. Phone/Fax

Practice location:
  • Phone: 302-993-7890
  • Fax: 302-993-7894
Mailing address:
  • Phone: 302-999-0137
  • Fax: 302-999-1042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN A CASSIDY
Title or Position: ADMINISTRATOR
Credential:
Phone: 302-993-7890