Basic Information
| Provider Information | |||||||||
| NPI: | 1194707380 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MERCY FITZGERALD SURGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W ELM ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105676964 | ||||||||
| FaxNumber: | 6105676170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 LANSDOWNE AVE | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | DARBY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190231333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105346170 | ||||||||
| FaxNumber: | 6105346159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 11/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6105676964 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3955657 | 01 | PA | AETNA | OTHER | 2414129000 | 01 | PA | KHPE | OTHER | 5746424 | 01 | PA | CIGNA | OTHER | 1007787930153 | 05 | PA | MEDICAID | 30023892 | 01 | PA | KEYSTONE MECY | OTHER | 1738463 | 01 | PA | BLUE SHIELD | OTHER | DA5351 | 01 | PA | RAILROAD MEDICARE | OTHER |