1942324330 NPI number — PMSI COLLEGEVILLE FAMILY PRACTICE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942324330 NPI number — PMSI COLLEGEVILLE FAMILY PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PMSI COLLEGEVILLE FAMILY PRACTICE
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:
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 Information

NPI Number:
1942324330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 SECOND AVENUE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
COLLEGEVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-454-7750
Provider Business Mailing Address Fax Number:
610-454-1367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 SECOND AVENUE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
COLLEGEVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-454-7750
Provider Business Practice Location Address Fax Number:
610-454-1367
Provider Enumeration Date:
03/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ENOCHS
Authorized Official First Name:
SHANA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
610-327-4200

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD046620L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 26191 . This is a "BLUE SHIELD ASSIGN ACCT" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0045725015 . This is a "KEYSTONE HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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