Basic Information
| Provider Information | |||||||||
| NPI: | 1255686150 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NAZARETH PHYSICIAN SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MERCY CARDIOLOGY AT NAZARETH | ||||||||
| 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: | 6105676967 | ||||||||
| FaxNumber: | 6105676955 | ||||||||
| Practice Location | |||||||||
| Address1: | 2701 HOLME AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191522029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153354944 | ||||||||
| FaxNumber: | 2153313619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | KIRBY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2153356614 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.