Provider Demographics
NPI:1104013085
Name:EAST NORRITON PHYSICIANS SERVICES
Entity Type:Organization
Organization Name:EAST NORRITON PHYSICIANS SERVICES
Other - Org Name:MERCY SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:B
Authorized Official - Last Name:KENNIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-631-2159
Mailing Address - Street 1:1 W ELM ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-4108
Mailing Address - Country:US
Mailing Address - Phone:610-567-6967
Mailing Address - Fax:610-567-6170
Practice Address - Street 1:716 W GERMANTOWN PIKE
Practice Address - Street 2:
Practice Address - City:EAST NORRITON
Practice Address - State:PA
Practice Address - Zip Code:19403-4255
Practice Address - Country:US
Practice Address - Phone:610-631-2159
Practice Address - Fax:610-631-7645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2097129000OtherKHPE
PA1026335OtherKMHP
PA5178482OtherAUSHC PPO
PA5399OtherAUSHC HMO
PADE1404878OtherHIGHMARK BLUE SHIELD
PA100759466 0038Medicaid
PA202264000OtherOWCP
PA061601Medicare PIN
PADE1404878OtherHIGHMARK BLUE SHIELD