Basic Information
| Provider Information | |||||||||
| NPI: | 1699726844 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NAZARETH PHYSICIAN SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W ELM ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105676967 | ||||||||
| FaxNumber: | 6105676170 | ||||||||
| Practice Location | |||||||||
| Address1: | 2701 HOLME AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191522029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155431026 | ||||||||
| FaxNumber: | 2153381250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 12/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | CASTLE | ||||||||
| AuthorizedOfficialFirstName: | LANCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SIR DIR PHYSICIAN BILLING | ||||||||
| AuthorizedOfficialTelephone: | 6105675520 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 2086S0129X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2457876000 | 01 | PA | IBC# | OTHER | 1014655140002 | 05 | PA | MEDICAID | 425807 | 01 | PA | AETNA OFFICE # | OTHER | NA1775677 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |