Provider Demographics
NPI:1124012828
Name:EAST NORRITON PHYSICIANS SERVICES
Entity Type:Organization
Organization Name:EAST NORRITON PHYSICIANS SERVICES
Other - Org Name:BRIDGEPORT FAMILY PRACTICE
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:610-567-6967
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:19428-2007
Mailing Address - Country:US
Mailing Address - Phone:610-567-6967
Mailing Address - Fax:610-567-6955
Practice Address - Street 1:700 DEKALB ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:PA
Practice Address - Zip Code:19405-1149
Practice Address - Country:US
Practice Address - Phone:610-277-6200
Practice Address - Fax:610-277-3437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0899194001OtherKHPE
PA0899194001OtherKMHP
PA298OtherAUSHC OFFICE NUMBER
PA5176213OtherAUSHC PPO
PA0018011OtherAUSHC HMO
PA1007594660059Medicaid
PA852929OtherHIGHMARK BLUE SHIELD
PA1007594660059Medicaid
PA043324Medicare PIN