Provider Demographics
NPI:1548301005
Name:SOUTHERN DELAWARE FOOT & ANKLE LLC
Entity type:Organization
Organization Name:SOUTHERN DELAWARE FOOT & ANKLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:T
Authorized Official - Last Name:LEMON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:302-629-3000
Mailing Address - Street 1:PO BOX 772
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-0772
Mailing Address - Country:US
Mailing Address - Phone:302-629-3613
Mailing Address - Fax:302-629-2384
Practice Address - Street 1:543 N SHIPLEY ST
Practice Address - Street 2:SUITE C
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-2339
Practice Address - Country:US
Practice Address - Phone:302-629-3000
Practice Address - Fax:302-629-3080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEE1-0000121213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE8699345001OtherCIGNA
DE448142OtherOPTIMUM CHOICE
DEP00062710OtherRAILROAD MEDICARE
DE2220599000OtherAMERIHEALTH
DE3314440OtherAETNA - PPO
DE1000025919Medicaid
DE2161OtherCOVENTRY
DE3316680OtherAETNA - HMO
DE510401832OtherBLUE CROSS BLUE SHIELD
DEG01460Medicare ID - Type Unspecified
DE1000025919Medicaid
DE448142OtherOPTIMUM CHOICE