Basic Information
| Provider Information | |||||||||
| NPI: | 1962497131 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HR PHYSICIAN SERVICES | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOMERTON FAMILY MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500 | ||||||||
| Address2: | BOX #4801 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191784081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158561010 | ||||||||
| FaxNumber: | 2154647865 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 BUSTLETON AVENUE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FEASTERVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154649599 | ||||||||
| FaxNumber: | 2154647865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2158561114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 232523377 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0098660 | 01 | PA | AETNA US HEALTHCARE | OTHER | 0391360001 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER | 100416 | 05 | PA | MEDICAID |