Basic Information
| Provider Information | |||||||||
| NPI: | 1144540337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIXVILLE MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | POTTSTOWN MEDICAL SPECIALISTS PHOENIXVILLE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1610 MEDICAL DRIVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | POTTSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103274200 | ||||||||
| FaxNumber: | 6103278160 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 GAY STREET | ||||||||
| Address2: | |||||||||
| City: | PHOENIXVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109357500 | ||||||||
| FaxNumber: | 6109354338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2010 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRISON | ||||||||
| AuthorizedOfficialFirstName: | KATIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMMUNICATIONS ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6103274200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POTTSTOWN MEDICAL SPECIALISTS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD024972E | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0007964850006 | 05 | PA | MEDICAID | 026191 | 01 | PA | BLUE SHIELD | OTHER |