1598755340 NPI number — MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA

Table of content: (NPI 1598755340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598755340 NPI number — MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
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 MEDICAL ASSOCIATES AT PROVIDENCE
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:
1598755340
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2008
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:
2ND FLOOR
Provider Business Mailing Address City Name:
CONSHOHOCKEN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19428-2007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-567-6964
Provider Business Mailing Address Fax Number:
610-567-6170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
831 PROVIDENCE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SECANE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19018-2921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-934-1234
Provider Business Practice Location Address Fax Number:
610-934-4811
Provider Enumeration Date:
10/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
VP FINANCIAL SERVICES
Authorized Official Telephone Number:
610-567-6964

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1007787930172 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2455345001 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 37229 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30035743 . This is a "KEYSTONE MERCY HEALTHPLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1147948 . This is a "AETNA HMO PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1772599 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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