Provider Demographics
NPI:1346285376
Name:MERCY MANAGEMENT OF SE PA
Entity Type:Organization
Organization Name:MERCY MANAGEMENT OF SE PA
Other - Org Name:MERCY FITZGERALD CRNA SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:CAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-237-4280
Mailing Address - Street 1:PO BOX 827675
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-7675
Mailing Address - Country:US
Mailing Address - Phone:856-423-7700
Mailing Address - Fax:856-423-0823
Practice Address - Street 1:1500 LANSDOWNE AVENUE
Practice Address - Street 2:
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023
Practice Address - Country:US
Practice Address - Phone:610-237-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY MANAGEMENT OF SE PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-16
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007787930164Medicaid
DB6047OtherRAILROAD MEDICARE GROUP
PA064756Medicare PIN