Basic Information
| Provider Information | |||||||||
| NPI: | 1710002936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PMSI DIVISION OF RHEUMATOLOGY | ||||||||
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| OtherOrganizationName: | POTTSTOWN MEDICAL SPECIALISTS RHEUMATOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | POTTSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194643241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103274200 | ||||||||
| FaxNumber: | 6103278160 | ||||||||
| Practice Location | |||||||||
| Address1: | 1566 MEDICAL DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | POTTSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194643229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4849450075 | ||||||||
| FaxNumber: | 4849450781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | ENOCHS | ||||||||
| AuthorizedOfficialFirstName: | SHANA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6103274200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POTTSTOWN MEDICAL SPECIALISTS, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | OS009934L | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 1392933 | 01 | PA | BLUE SHIELD ASSIGN ACCT | OTHER | 2082006000 | 01 | KEYSTONE HMO | OTHER |