Basic Information
| Provider Information | |||||||||
| NPI: | 1710470323 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST MARY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST MARY ADULT HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 UNIVERSITY DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | NEWTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189401873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157105522 | ||||||||
| FaxNumber: | 2157105181 | ||||||||
| Practice Location | |||||||||
| Address1: | 2546B KNIGHTS RD | ||||||||
| Address2: | |||||||||
| City: | BENSALEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156338397 | ||||||||
| FaxNumber: | 2156423588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2018 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | PROFERA | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2157102013 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST MARY MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.