Basic Information
| Provider Information | |||||||||
| NPI: | 1124012828 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST NORRITON PHYSICIANS SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRIDGEPORT FAMILY PRACTICE | ||||||||
| 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: | 700 DEKALB ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194051149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102776200 | ||||||||
| FaxNumber: | 6102773437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
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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 | 0899194001 | 01 | PA | KHPE | OTHER | 0899194001 | 01 | PA | KMHP | OTHER | 298 | 01 | PA | AUSHC OFFICE NUMBER | OTHER | 5176213 | 01 | PA | AUSHC PPO | OTHER | 0018011 | 01 | PA | AUSHC HMO | OTHER | 1007594660059 | 05 | PA | MEDICAID | 852929 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |