Healthcare Provider Details

I. General information

NPI: 1144846197
Provider Name (Legal Business Name): OLIVE BRANCH MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411 SILVERSIDE RD # 102
WILMINGTON DE
19810-4812
US

IV. Provider business mailing address

530 HARLAN BLVD UNIT 404
WILMINGTON DE
19801-5170
US

V. Phone/Fax

Practice location:
  • Phone: 302-992-8310
  • Fax: 662-214-6092
Mailing address:
  • Phone: 443-718-9470
  • Fax: 662-214-6092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AMY ZHANG
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 443-718-9470