=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255889572
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOMATUS NEPHROLOGY OF DELAWARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2016
-----------------------------------------------------
Last Update Date | 09/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 STANTON CHRISTIANA RD SUITE 101
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19713-2133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-495-7662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1650 TYSONS BLVD SUITE 900
-----------------------------------------------------
City | MC LEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22102-4856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-495-7662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS CONSULTANT
-----------------------------------------------------
Name | SHAWANA LYNN DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 240-299-6991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------