Basic Information
| Provider Information | |||||||||
| NPI: | 1891771994 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MMS-MERCY ORTHPAEDICS ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W ELM ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105676964 | ||||||||
| FaxNumber: | 6105676170 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S 54TH ST | ||||||||
| Address2: | SUITE 28 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191431900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157489822 | ||||||||
| FaxNumber: | 2157489717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6105676964 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | MD042497 | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XS0114X | MD047458 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1007787930159 | 05 | PA | MEDICAID | 1251834000 | 01 | PA | DEPARTMENT OF LABOR | OTHER | 2957200 | 01 | PA | AETNA HMO | OTHER | 30010804 | 01 | PA | KERYSTONE MERCY HEALTH PL | OTHER | 1544388 | 01 | PA | BLUE SHIELD | OTHER | 2228682000 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER | 33316 | 01 | PA | HEALTH PARTNERS | OTHER |