Provider Demographics
NPI:1376610725
Name:ST MARY MANOR
Entity Type:Organization
Organization Name:ST MARY MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CZEKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-368-0900
Mailing Address - Street 1:701 LANSDALE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-2958
Mailing Address - Country:US
Mailing Address - Phone:215-368-0900
Mailing Address - Fax:215-368-5254
Practice Address - Street 1:701 LANSDALE AVE
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2958
Practice Address - Country:US
Practice Address - Phone:215-368-0900
Practice Address - Fax:215-368-5254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA451402332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0650000001Medicare NSC