Provider Demographics
NPI:1083622286
Name:ST MARY MEDICAL CENTER
Entity Type:Organization
Organization Name:ST MARY MEDICAL CENTER
Other - Org Name:ST. MARY FAMILY MEDICINE BENSALEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRILLIANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-710-2020
Mailing Address - Street 1:41 UNIVERSITY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1873
Mailing Address - Country:US
Mailing Address - Phone:215-710-5522
Mailing Address - Fax:215-710-5181
Practice Address - Street 1:3331 STREET RD STE 140
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-2046
Practice Address - Country:US
Practice Address - Phone:215-245-8873
Practice Address - Fax:215-245-8895
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-03
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007731420023Medicaid