=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548301005
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN DELAWARE FOOT & ANKLE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 04/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 543 N SHIPLEY ST SUITE C
-----------------------------------------------------
City | SEAFORD
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19973-2339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-629-3000
-----------------------------------------------------
Fax | 302-629-3080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 772
-----------------------------------------------------
City | SEAFORD
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19973-0772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-629-3613
-----------------------------------------------------
Fax | 302-629-2384
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRADLEY T LEMON
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 302-629-3000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | E1-0000121
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------