Basic Information
| Provider Information | |||||||||
| NPI: | 1902808306 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST NORRITON PHYSICIANS SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MERCY INTERNAL MEDICINE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 6105676955 | ||||||||
| Practice Location | |||||||||
| Address1: | 2705 DEKALB PIKE | ||||||||
| Address2: | SUITE 309 | ||||||||
| City: | NORRISTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194011852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102750200 | ||||||||
| FaxNumber: | 6102754436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENNIFF | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6105676967 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2228688000 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER | 1544454 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 30007454 | 01 | PA | KEYSTONE MERCY | OTHER | 2228688001 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER | 6294024001 | 01 | PA | CIGNA | OTHER | 3248775 | 01 | PA | AUSHC HMO | OTHER | 1007594660058 | 05 | PA | MEDICAID |