=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255465571
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES R MULLIGAN JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2007
-----------------------------------------------------
Last Update Date | 11/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4701 OGLETOWN STANTON ROAD HELEN F. GRAHAM CANCER CENTER, SUITE 2100
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-623-4530
-----------------------------------------------------
Fax | 434-200-5307
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 HYGEIA DR SUITE 2300
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19713-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-200-3100
-----------------------------------------------------
Fax | 434-200-5307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | 15191
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------