Basic Information
| Provider Information | |||||||||
| NPI: | 1245451426 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POTTSTOWN MEDICAL SPECIALISTS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KIMBERTON MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1591 MEDICAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | POTTSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103268005 | ||||||||
| FaxNumber: | 6103279629 | ||||||||
| Practice Location | |||||||||
| Address1: | 1591 MEDICAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | POTTSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103268005 | ||||||||
| FaxNumber: | 6103279629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 08/18/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRISON | ||||||||
| AuthorizedOfficialFirstName: | KATIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COMMUNICATIONS ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6103274200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POTTSTOWN MEDICAL SPECIALISTS, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD023984E | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0045725010 | 01 | PA | KEYSTONE GROUP NUMBER | OTHER |