Basic Information
Provider Information | |||||||||
NPI: | 1295818961 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHERWIN | ||||||||
FirstName: | NANCY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 255 W LANCASTER AVE | ||||||||
Address2: |   | ||||||||
City: | PAOLI | ||||||||
State: | PA | ||||||||
PostalCode: | 193011763 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6106481000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 255 W LANCASTER AVE | ||||||||
Address2: |   | ||||||||
City: | PAOLI | ||||||||
State: | PA | ||||||||
PostalCode: | 193011763 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6106481000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2006 | ||||||||
LastUpdateDate: | 09/02/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | MD024208E | PA | N |   | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | MD024208E | PA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 0057327000 | 01 | PA | KEYSTONE HEALTHPLAN EAST | OTHER | 106537 | 01 | PA | BLUE SHIELD PA | OTHER | 2581870 | 01 | PA | AETNA | OTHER | 0100375005 | 01 | PA | AMERICHOICE | OTHER | 0010037500004 | 05 | PA |   | MEDICAID |