Provider Demographics
NPI:1437279858
Name:PRESBYTERIAN MULTI-SPECIALTY GROUP
Entity Type:Organization
Organization Name:PRESBYTERIAN MULTI-SPECIALTY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-662-2286
Mailing Address - Street 1:3624 MARKET ST
Mailing Address - Street 2:SUITE 560W
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2614
Mailing Address - Country:US
Mailing Address - Phone:215-662-2286
Mailing Address - Fax:
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:3910 BUILDING, 2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-662-2289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207N00000X, 207RC0000X, 207RH0003X, 207RR0500X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Not Answered207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Not Answered207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Not Answered208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007726820Medicaid
PA1046781OtherKEYSTONE MERCY
PA767057OtherBLUE SHIELD
PA0710826000OtherKEYSTONE
PA16972OtherHEALTHPARTNERS
PA472891OtherAETNA
PA767057K5BMedicare ID - Type Unspecified