Basic Information
| Provider Information | |||||||||
| NPI: | 1518397116 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NAZARETH PHYSICIAN SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NAZARETH ONCOLOGY | ||||||||
| 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: | 6105676964 | ||||||||
| FaxNumber: | 6105676955 | ||||||||
| Practice Location | |||||||||
| Address1: | 2701 HOLME AVE | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191522029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105675336 | ||||||||
| FaxNumber: | 6105676955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2013 | ||||||||
| LastUpdateDate: | 08/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | HILKER | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6105675529 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 207RX0202X | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 095918 | 01 | PA | MEDICARE GROUP PTAN | OTHER |