Provider Demographics
NPI:1184678666
Name:FORNANCE PHYSICIAN SERVICES, INC
Entity Type:Organization
Organization Name:FORNANCE PHYSICIAN SERVICES, INC
Other - Org Name:BROAD AXE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PHYSICIAN BILLING
Authorized Official - Prefix:
Authorized Official - First Name:VERA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETT-ROBINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-622-7391
Mailing Address - Street 1:PO BOX 789967
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-9967
Mailing Address - Country:US
Mailing Address - Phone:484-622-7395
Mailing Address - Fax:484-622-7399
Practice Address - Street 1:721 SKIPPACK PIKE
Practice Address - Street 2:SUITE 3
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-1700
Practice Address - Country:US
Practice Address - Phone:215-793-0600
Practice Address - Fax:610-793-0759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA259541OtherHIGHMARK BLUE SHIELD
PA2120908OtherALLIANCE (MAMSI)
PA0274457001OtherIBC - PC/KHPE
PA33022OtherHEALTH PARTNERS SITE #
PA085595OtherAETNA HMO
PA1065049OtherKEYSTONE MERCY
PA5389597OtherAETNA PPO
PA0274457001OtherAMERIHEALTH/INTERCOUNTY
PA7990725OtherCIGNA HMO/PPO
PACI5397OtherRRM
PA1065049OtherKEYSTONE MERCY