Basic Information
| Provider Information | |||||||||
| NPI: | 1265956973 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANI | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MMSEPA P PCP CHESTNUT OFFICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W ELM ST | ||||||||
| Address2: | |||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194284108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105676964 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5630 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157483100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2017 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | HOPKINS | ||||||||
| AuthorizedOfficialFirstName: | BETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR BILLING | ||||||||
| AuthorizedOfficialTelephone: | 6105675239 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207Q00000X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.