1770563082 NPI number — FORNANCE PHYSICIAN SERVICES, INC

Table of content: (NPI 1770563082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770563082 NPI number — FORNANCE PHYSICIAN SERVICES, INC

Organization/Personal Information

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's Other Name Information

Provider Other Organization Name:
RADIOLOGY 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 Information

NPI Number:
1770563082
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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's Practice Location Mailing Address

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:
484-622-0700
Provider Business Practice Location Address Fax Number:
484-622-0643
Provider Enumeration Date:
01/20/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 2085B0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0203X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 444921 . This is a "HIGHMARK BLUE SHIELD" 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".
  • Identifier: 46128 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0700330901 . This is a "AMERICHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0046835000 . This is a "IBC - PC, KHPE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0046835000 . This is a "AMERIHEALTH/INTERCOUNTY" 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: CK3574 . This is a "RR MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0282548 . This is a "CIGNA HMO/PPO" 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".




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