Basic Information
| Provider Information | |||||||||
| NPI: | 1821089848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY SUBURBAN HOSPITAL | ||||||||
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| OtherOrganizationName: | MERCY SUBURBAN FAMILY PRACTICE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 530 CHURCH ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | NORRISTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194014811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102757240 | ||||||||
| FaxNumber: | 6102751381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 10/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | V.P., PAT. FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6105676967 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100136 | 01 | PA | KMHP | OTHER | 202259700 | 01 | PA | OWCP | OTHER | 594466 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | X0004043 01 | 01 | PA | AMERICHOICE | OTHER | 85753 | 01 | PA | AUSHC CAP NUMBER | OTHER | 0222562002 | 01 | PA | KEYSTONE HEALTHPLAN EAST | OTHER | 1007277020017 | 05 | PA | MEDICAID |