Provider Demographics
NPI:1407839038
Name:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Entity Type:Organization
Organization Name:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Other - Org Name:MMS-MERCY PATHOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCIAL SVCS
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-567-6964
Mailing Address - Street 1:1 W ELM ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2007
Mailing Address - Country:US
Mailing Address - Phone:610-567-6964
Mailing Address - Fax:610-567-6170
Practice Address - Street 1:1500 LANSDOWNE AVE
Practice Address - Street 2:
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-1200
Practice Address - Country:US
Practice Address - Phone:610-237-4544
Practice Address - Fax:610-237-5689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0451229OtherAETNA HMO
PA446465OtherBLUE SHIELD
PA1007787930071Medicaid
PA33201OtherKEYSTONE MERCY HEALTH PLA
PA4482939OtherAETNA PPO
PA026795OtherHEALTH PARTNERS
PA2049124000OtherDEPARTMENT OF LABOR
PA0032615000OtherKEYSTONE HEALTH PLAN EAST
PA1007787930071Medicaid
PA446465Medicare PIN