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General NPI Number Information
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NPI Number | 1114512068
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Entity Type | Organization
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Legal Business Name | STATE OF DELAWARE
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Dates
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Enumeration Date | 03/03/2021
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Last Update Date | 03/03/2021
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Provider Practice Location Address
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Address Line | 660 BAYLOR BLVD
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City | NEW CASTLE
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State | DE
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Zip | 19720-1140
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Country | US
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Telephone | 302-577-3004
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Fax |
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Provider Business Mailing Address
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Address Line | 245 MCKEE RD
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City | DOVER
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State | DE
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Zip | 19904-2232
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. AWELE N. MADUKA-EZEH
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Credential |
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Telephone | 302-739-5601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2400X
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Taxonomy Name | Prison Health Clinic/Center
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License Number |
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License Number State |
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