1801876958 NPI number — FORNANCE PHYSICIAN SERVICES, INC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801876958 NPI number — FORNANCE PHYSICIAN SERVICES, INC

Employer Identification Number (EIN):

Provider Organization Name:

FORNANCE PHYSICIAN SERVICES, INC

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

ANESTHESIA GROUP FORNANCE

Provider Other Organization Name Type Code:

3

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1801876958

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

08/17/2018

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 8500-9967

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

PHILADELPHIA

Provider Business Mailing Address State Name:

PA

Provider Business Mailing Address Postal Code:

19178-9967

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

484-622-7395

Provider Business Mailing Address Fax Number:

484-622-7399

Provider First Line Business Practice Location Address:

559 W GERMANTOWN PIKE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

EAST NORRITON

Provider Business Practice Location Address State Name:

PA

Provider Business Practice Location Address Postal Code:

19403-4250

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

484-622-1244

Provider Business Practice Location Address Fax Number:

484-622-1542

Provider Enumeration Date:

01/17/2006

Authorized Official Last Name:

LOWE-ROBBINS

Authorized Official First Name:

KAREN

Authorized Official Middle Name:

Authorized Official Title or Position:

REIMBURSEMENT MANAGER

Authorized Official Telephone Number:

484-622-7382

• Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 1738323 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 0046639000 . This is a "(IBC) KHPE & PC GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 08726 . This is a "HEALTH PARTNERS GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 8495175 . This is a "AETNA PPO GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 444993 . This is a "BLUE SHIELD GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 48811 . This is a "KEYSTONE MERCY GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 898188 . This is a "AETNA HMO GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: G0001883 . This is a "AMERICHOICE GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".