Provider Demographics
NPI:1114041514
Name:POTTSTOWN MEDICAL SPECIALISTS INC
Entity Type:Organization
Organization Name:POTTSTOWN MEDICAL SPECIALISTS INC
Other - Org Name:BOYERTOWN MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ENOCHS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-327-4200
Mailing Address - Street 1:23 N. WALNUT STREET
Mailing Address - Street 2:
Mailing Address - City:BOYERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19512
Mailing Address - Country:US
Mailing Address - Phone:610-367-2259
Mailing Address - Fax:610-367-0505
Practice Address - Street 1:23 N. WALNUT ST
Practice Address - Street 2:
Practice Address - City:BOYERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19512
Practice Address - Country:US
Practice Address - Phone:610-367-2259
Practice Address - Fax:610-367-0505
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOYERTOWN MEDICAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-19
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008215L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0045725013OtherKEYSTONE HMO
PA26191OtherBLUE SHIELD ASSIGN ACCT
PA26191OtherBLUE SHIELD ASSIGN ACCT