Basic Information
| Provider Information | |||||||||
| NPI: | 1396857504 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MANAGEMENT OF SEPA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCY ORTHOPEDIC GROUP | ||||||||
| 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: | 6105676170 | ||||||||
| Practice Location | |||||||||
| Address1: | 433 S LANSDOWNE AVE | ||||||||
| Address2: | |||||||||
| City: | YEADON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190502405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106269800 | ||||||||
| FaxNumber: | 6102374202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 02/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNTS VP | ||||||||
| AuthorizedOfficialTelephone: | 6105676967 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | V.P. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1007787930170 | 05 | PA | MEDICAID | 2760128000 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER | 1893659 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 30035145 | 01 | PA | KEYSTONE MERCY HEALTH | OTHER |