Basic Information
| Provider Information | |||||||||
| NPI: | 1598755340 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCY MEDICAL ASSOCIATES AT PROVIDENCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 831 PROVIDENCE RD | ||||||||
| Address2: | |||||||||
| City: | SECANE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190182921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109341234 | ||||||||
| FaxNumber: | 6109344811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 03/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6105676964 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 1007787930172 | 05 | PA | MEDICAID | 2455345001 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER | 37229 | 01 | PA | HEALTHPARTNERS | OTHER | 30035743 | 01 | PA | KEYSTONE MERCY HEALTHPLAN | OTHER | 1147948 | 01 | PA | AETNA HMO PPO | OTHER | 1772599 | 01 | PA | BLUE SHIELD | OTHER |