Basic Information
| Provider Information | |||||||||
| NPI: | 1104013085 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST NORRITON PHYSICIANS SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MERCY SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W ELM ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194284108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105676967 | ||||||||
| FaxNumber: | 6105676170 | ||||||||
| Practice Location | |||||||||
| Address1: | 716 W GERMANTOWN PIKE | ||||||||
| Address2: | |||||||||
| City: | EAST NORRITON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194034255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106312159 | ||||||||
| FaxNumber: | 6106317645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2007 | ||||||||
| LastUpdateDate: | 08/22/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENNIFF | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6106312159 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2097129000 | 01 | PA | KHPE | OTHER | 1026335 | 01 | PA | KMHP | OTHER | 5178482 | 01 | PA | AUSHC PPO | OTHER | 5399 | 01 | PA | AUSHC HMO | OTHER | DE1404878 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 100759466 0038 | 05 | PA | MEDICAID | 202264000 | 01 | PA | OWCP | OTHER |