Healthcare Provider Details

I. General information

NPI: 1508947482
Provider Name (Legal Business Name): FIRST STATE DIAGNOSTIC CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 PENNSYLVANIA AVE SUITE 101
WILMINGTON DE
19806-1401
US

IV. Provider business mailing address

2401 PENNSYLVANIA AVE SUITE 101
WILMINGTON DE
19806-1401
US

V. Phone/Fax

Practice location:
  • Phone: 302-777-1103
  • Fax: 302-777-1113
Mailing address:
  • Phone: 302-777-1103
  • Fax: 302-777-1113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License NumberC1-0004005
License Number StateDE

VIII. Authorized Official

Name: DR. KAMAR TAYO ADELEKE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 302-777-1103