1104096593 NPI number — EAST NORRITON PHYSICIANS SERVICES

Table of content: (NPI 1104096593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104096593 NPI number — EAST NORRITON PHYSICIANS SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST NORRITON PHYSICIANS SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MERCY FAMILY MEDICINE OF EAST NORRITON
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 Information

NPI Number:
1104096593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 W ELM ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CONSHOHOCKEN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19428-4108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-567-6967
Provider Business Mailing Address Fax Number:
610-567-6170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 W GERMANTOWN PIKE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
EAST NORRITON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19401-1385
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-272-0190
Provider Business Practice Location Address Fax Number:
610-272-4428
Provider Enumeration Date:
03/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KENNIFF
Authorized Official First Name:
PETER
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
610-567-6967

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2025321 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3424972001 . This is a "IBC/KHPE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007594660066 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30050608 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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