Basic Information
| Provider Information | |||||||||
| NPI: | 1124011929 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST NORRITON PHYSICIANS SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BLUE BELL FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W ELM ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105676967 | ||||||||
| FaxNumber: | 6105676955 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 SKIPPACK PIKE | ||||||||
| Address2: | PAREC PLAZA 2ND FLOOR | ||||||||
| City: | BLUE BELL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194221741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155421300 | ||||||||
| FaxNumber: | 2156433123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | KENNIFF | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6105676967 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30029546 | 01 | PA | KMHP | OTHER | 427 | 01 | PA | AETNA OFFICE NUMBER | OTHER | 000040925 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 4422178 | 01 | PA | AUSHC PPO | OTHER | 1007594660064 | 05 | PA | MEDICAID | 0019286 | 01 | PA | AUSHC HMO | OTHER | 0707702001 | 01 | PA | KHPE | OTHER | 202608200 | 01 | PA | OWCP | OTHER |