Basic Information
| Provider Information | |||||||||
| NPI: | 1770506750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY MANAGEMENT OF SEPA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WEST PHILADELPHIA WOMEN FIRST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5346 CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191431918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157476661 | ||||||||
| FaxNumber: | 2154711418 | ||||||||
| Practice Location | |||||||||
| Address1: | 5346 CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191431918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157476661 | ||||||||
| FaxNumber: | 2154711418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 09/25/2007 | ||||||||
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| AuthorizedOfficialLastName: | HALBERSTADT | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2157489300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1007787930093 | 05 | PA | MEDICAID |