Provider Demographics
NPI:1609260397
Name:TRINITY HEALTH MID-ATLANTIC MEDICAL GROUP
Entity Type:Organization
Organization Name:TRINITY HEALTH MID-ATLANTIC MEDICAL GROUP
Other - Org Name:ST. MARY FAMILY PRACTICE - RICHBORO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:PROFERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-710-2013
Mailing Address - Street 1:41 UNIVERSITY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1873
Mailing Address - Country:US
Mailing Address - Phone:215-710-7037
Mailing Address - Fax:215-710-5181
Practice Address - Street 1:95 ALMSHOUSE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:RICHBORO
Practice Address - State:PA
Practice Address - Zip Code:18954-1154
Practice Address - Country:US
Practice Address - Phone:215-357-5760
Practice Address - Fax:215-357-5731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-20
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007497370052Medicaid
PA4196193OtherAETNA
PA3156947OtherHIGHMARK BLUE SHIELD
PA30212269OtherKEYSTONE FIRST
PA3920999003OtherKEYSTONE IBC
PACA4059OtherRAILROAD MEDICARE
PA3156947OtherHIGHMARK BLUE SHIELD