Provider Demographics
NPI:1447606421
Name:HR PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:HR PHYSICIAN SERVICES
Other - Org Name:PEDICINO PRIMARY CARE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT, FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:R
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-856-1114
Mailing Address - Street 1:12265 TOWNSEND RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19154-1201
Mailing Address - Country:US
Mailing Address - Phone:215-856-1010
Mailing Address - Fax:215-698-3730
Practice Address - Street 1:1650 HUNTINGDON PIKE
Practice Address - Street 2:SUITE 301
Practice Address - City:MEADOWBROOK
Practice Address - State:PA
Practice Address - Zip Code:19046-8001
Practice Address - Country:US
Practice Address - Phone:215-947-8170
Practice Address - Fax:215-947-8572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017974E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB38545Medicare UPIN
PA137351Medicare PIN