Basic Information
| Provider Information | |||||||||
| NPI: | 1457382053 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NAZARETH PHYSICIAN SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W ELM ST | ||||||||
| Address2: | |||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105676967 | ||||||||
| FaxNumber: | 6105676170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1407 RHAWN STREET | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157226022 | ||||||||
| FaxNumber: | 2157226547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | KIRBY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2153356614 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 101465514 0002 | 05 | PA | MEDICAID | 2457876003 | 01 | PA | IBC# | OTHER | 425807 | 01 | PA | AETNA OFFICE # | OTHER | 30029001 | 01 | PA | KMHP | OTHER | NA1775677 | 01 | PA | BLUE SHIELD | OTHER |