Basic Information
| Provider Information | |||||||||
| NPI: | 1669723722 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENPS MERCY PRIMARY CARE AT PLYMOUTH MEETING | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCY PRIMARY CARE AT PLYMOUTH MEETING | ||||||||
| 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: | 6105675265 | ||||||||
| FaxNumber: | 6105676955 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W GERMANTOWN PIKE | ||||||||
| Address2: | SUITE 1020 | ||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194621353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109414208 | ||||||||
| FaxNumber: | 6109414158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2012 | ||||||||
| LastUpdateDate: | 09/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | MUNIZ | ||||||||
| AuthorizedOfficialFirstName: | ANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6105675265 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAST NORRITON PHYSICIAN SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.