Basic Information
| Provider Information | |||||||||
| NPI: | 1396286233 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY CATHOLIC MEDICAL CENTER OF SOUTHEASTERN PENNSYLVANIA | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MERCY FITZGERALD HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 832 ARBOR RD | ||||||||
| Address2: | |||||||||
| City: | YEADON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190503602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103042550 | ||||||||
| FaxNumber: | 6102592932 | ||||||||
| Practice Location | |||||||||
| Address1: | 832 ARBOR RD | ||||||||
| Address2: | |||||||||
| City: | YEADON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190503602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103042550 | ||||||||
| FaxNumber: | 6102592932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2017 | ||||||||
| LastUpdateDate: | 03/11/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MISSRI | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6102374980 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | SP017020 | PA | Y | Hospitals | General Acute Care Hospital |
No ID Information.