Provider Demographics
NPI:1598755340
Name:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Entity Type:Organization
Organization Name:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Other - Org Name:MERCY MEDICAL ASSOCIATES AT PROVIDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCIAL SERVICES
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 1:831 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:SECANE
Practice Address - State:PA
Practice Address - Zip Code:19018-2921
Practice Address - Country:US
Practice Address - Phone:610-934-1234
Practice Address - Fax:610-934-4811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007787930172Medicaid
PA2455345001OtherKEYSTONE HEALTH PLAN EAST
PA37229OtherHEALTHPARTNERS
PA30035743OtherKEYSTONE MERCY HEALTHPLAN
PA1147948OtherAETNA HMO PPO
PA1772599OtherBLUE SHIELD
PA37229OtherHEALTHPARTNERS
PA1772599OtherBLUE SHIELD