Basic Information
| Provider Information | |||||||||
| NPI: | 1124206958 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MANAGEMENT OF SEPA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCY MEDICAL ASSOCIATES AT DARBY | ||||||||
| 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: | 6105676964 | ||||||||
| FaxNumber: | 6105676170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 LANSDOWNE AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DARBY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190231333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105346310 | ||||||||
| FaxNumber: | 6105346350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 02/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCIAL PATIENT SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6105676601 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS003117L | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.