Basic Information
| Provider Information | |||||||||
| NPI: | 1396721494 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MMS-MERCY HOSPITAL OF PHILADELPHIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W ELM ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105676964 | ||||||||
| FaxNumber: | 6105676170 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S 54TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191431900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157489707 | ||||||||
| FaxNumber: | 2157489708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6105676964 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 100778793 0157 | 05 | PA | MEDICAID | 1543646 | 01 | PA | BLUE SHIELD COMP | OTHER | 1543646 | 01 | PA | BLUE SHIELD PA PR | OTHER | 1543648 | 01 | PA | AMERIHEALTH ADMIN | OTHER | 2228313000 | 01 | PA | AMERIHEALTH DELAWARE | OTHER | 2228313000 | 01 | PA | BLUE SHIELD LLIN | OTHER | 33695 | 01 | PA | HEALTH PARTNERS SENIOR | OTHER | 1543646 | 01 | PA | BLUE SHIELD | OTHER | 2228313000 | 01 | PA | KEYSTONE 65 SPECIAL | OTHER | 2507496 | 01 | PA | AETNA MEDICARE HMO | OTHER | 2228313000 | 01 | PA | AMERIHEALTH HMO | OTHER | 2228313000 | 01 | PA | AMERIHEALTH NEW JERSEY | OTHER | 2228313000 | 01 | PA | KEYSTONE HEALTH PLAN | OTHER | 33695 | 01 | PA | HEALTH PARTNERS | OTHER | 125183600 | 01 | PA | DEPT OF LABOR | OTHER | 2507496 | 01 | PA | AETNA HMO SPECIALIST | OTHER | 1543646 | 01 | PA | BLUE SHIELD PA 65 | OTHER | 7770198 | 01 | PA | AETNA OTHER | OTHER | G000668600 | 01 | PA | AMERICHOICE | OTHER |