Provider Demographics
NPI:1164684601
Name:MT AIRY/ GERMANTOWN MEDICAL AND REHAB ASSOCIATES
Entity Type:Organization
Organization Name:MT AIRY/ GERMANTOWN MEDICAL AND REHAB ASSOCIATES
Other - Org Name:BROAD AND GRANGE FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-843-0672
Mailing Address - Street 1:5751 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-2307
Mailing Address - Country:US
Mailing Address - Phone:215-843-0672
Mailing Address - Fax:215-843-0674
Practice Address - Street 1:5751 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-2307
Practice Address - Country:US
Practice Address - Phone:215-843-0672
Practice Address - Fax:215-843-0674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061558L261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
2265537000OtherKHPE, PERSONAL CHOICE
PAHMO2590672OtherAETNA US HEALTHCARE
PA34699 MD061558LOtherHEALTHPARTNERS
PA954658OtherBLUE CROSS/ BLUE SHIELD
PA30010670OtherKEYSTONE MERCY
PA34699 MD061558LOtherHEALTHPARTNERS