Provider Demographics
NPI:1053450981
Name:ADOLESCENT MEDICINE GENERAL PEDIATRICS & ALLERGY
Entity type:Organization
Organization Name:ADOLESCENT MEDICINE GENERAL PEDIATRICS & ALLERGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FIZUL
Authorized Official - Middle Name:H
Authorized Official - Last Name:BACCHUS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:302-734-3331
Mailing Address - Street 1:863 BUTTNER PLACE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-2406
Mailing Address - Country:US
Mailing Address - Phone:302-734-3331
Mailing Address - Fax:302-734-9908
Practice Address - Street 1:863 BUTTNER PLACE
Practice Address - Street 2:SUITE 103
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-2406
Practice Address - Country:US
Practice Address - Phone:302-734-3331
Practice Address - Fax:302-734-9908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001036904Medicaid
E02320Medicare UPIN