Provider Demographics
NPI:1598112518
Name:NAZARETH PHYSICIAN SERVICES INC
Entity Type:Organization
Organization Name:NAZARETH PHYSICIAN SERVICES INC
Other - Org Name:MERCY CARDIOLOGY AT NAZ 100
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-567-6964
Mailing Address - Street 1:1 W ELM ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-4108
Mailing Address - Country:US
Mailing Address - Phone:610-567-6964
Mailing Address - Fax:610-567-5420
Practice Address - Street 1:2701 HOLME AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2029
Practice Address - Country:US
Practice Address - Phone:215-332-3972
Practice Address - Fax:215-331-3784
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAZARETH PHYSICIAN SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-19
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014655140001Medicaid