Basic Information
Provider Information | |||||||||
NPI: | 1952569022 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUFFY | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 191 | ||||||||
Address2: | PROVIDER ENROLLMENT DEPT | ||||||||
City: | ROCKLAND | ||||||||
State: | DE | ||||||||
PostalCode: | 197320191 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3026516212 | ||||||||
FaxNumber: | 3026514945 | ||||||||
Practice Location | |||||||||
Address1: | 1600 ROCKLAND ROAD | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | DE | ||||||||
PostalCode: | 198033607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3026514000 | ||||||||
FaxNumber: | 3026514945 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2008 | ||||||||
LastUpdateDate: | 12/14/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | 11013177A | IN | N |   | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 2086S0127X | 11013177A | IN | N |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0120X | C10008773 | DE | Y |   | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 2086S0120X | MD435223 | PA | N |   | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
ID | Type | State | Issuer | Description | 002634401 | 01 | MD | MD DEPT OF HLTH & MENTAL HYGIENE | OTHER | 0169668 | 01 | NJ | NJ DEPT OF HLTH DIVISION OF MEDICAL ASSIST & HLTH SVCS | OTHER | 1952569022 | 05 | DE |   | MEDICAID |