Basic Information
| Provider Information | |||||||||
| NPI: | 1427570019 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W ELM ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194284108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 16105675387 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 LANSDOWNE AVE | ||||||||
| Address2: | |||||||||
| City: | DARBY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190231333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105675387 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2017 | ||||||||
| LastUpdateDate: | 07/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | BRENNAN | ||||||||
| AuthorizedOfficialFirstName: | AMIEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6105676964 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY PAIN MANAGEMENT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.