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General NPI Number Information
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NPI Number | 1033190145
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Entity Type | Organization
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Legal Business Name | FIRST STATE MEDICAL PA
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Dates
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Enumeration Date | 11/07/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3521 SILVERSIDE RD QUILLEN BUILDING SUITE 2D1
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City | WILMINGTON
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State | DE
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Zip | 19810-4900
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Country | US
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Telephone | 302-479-0555
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Fax | 302-479-5006
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Provider Business Mailing Address
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Address Line | 3521 SILVERSIDE RD QUILLEN BUILDING SUITE 2D1
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City | WILMINGTON
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State | DE
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Zip | 19810-4900
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Country | US
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Telephone | 302-479-0555
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Fax | 302-479-5006
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | DR. HUGH BONNER III
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Credential | M.D.
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Telephone | 302-479-0555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | C10004738
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License Number State | DE
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