=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396780664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FENWICK MEDICAL CENTER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2006
-----------------------------------------------------
Last Update Date | 09/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 COASTAL HWY
-----------------------------------------------------
City | FENWICK ISLAND
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-581-0458
-----------------------------------------------------
Fax | 302-581-0460
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12036 S PINEY POINT RD
-----------------------------------------------------
City | BISHOPVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21813-1542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-430-5154
-----------------------------------------------------
Fax | 410-352-5430
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE OWNER
-----------------------------------------------------
Name | NICHOLAS NICHOLSON BORODULIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 302-581-0458
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | C10001802
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------