Basic Information
| Provider Information | |||||||||
| NPI: | 1730127820 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELAWARE COASTAL ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 785802 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191785802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8557094535 | ||||||||
| FaxNumber: | 3027330854 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 S BAY RD | ||||||||
| Address2: | STE 5B | ||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199014660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026784688 | ||||||||
| FaxNumber: | 3026784625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 03/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | RELOVA | ||||||||
| AuthorizedOfficialFirstName: | RODERICK | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3023314003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | DE | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1000028581 | 05 | DE | MEDICAID | DB7759 | 01 | DE | RAILROAD | OTHER |