1225018526 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 1225018526 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:

Provider Other Organization Name Type Code:

6

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:

1225018526

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:

484-622-1365

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

01/20/2006

Authorized Official Last Name:

BURNETT-ROBINS

Authorized Official First Name:

VERA

Authorized Official Middle Name:

Authorized Official Title or Position:

DIRECTOR PHYSICIAN BILLING

Authorized Official Telephone Number:

484-622-7391

• Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 30026844 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 08722 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 1738323 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1643760 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 23-2275591 . This is a "PHCS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 2319700000 . This is a "IBC - PC, KHPE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 0700330901 . This is a "AMERICHOICE/HMA (UHC MA)" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 23-2275591 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 2319700000 . This is a "AMERIHEALTH/INTERCOUNTY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 459451 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".