Provider Demographics
NPI:1710001136
Name:PMSI DIVISION OF CARDIOLOGY
Entity Type:Organization
Organization Name:PMSI DIVISION OF CARDIOLOGY
Other - Org Name:POTTSTOWN MEDICAL SPECIALISTS CARDIOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ENOCHS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-327-4200
Mailing Address - Street 1:1591 MEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464
Mailing Address - Country:US
Mailing Address - Phone:610-326-8005
Mailing Address - Fax:610-718-0788
Practice Address - Street 1:1591 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464
Practice Address - Country:US
Practice Address - Phone:610-326-8005
Practice Address - Fax:610-718-0788
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POTTSTOWN MEDICAL SPECIALIST, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-19
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD044234E207RC0000X
MD062953L207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA919371OtherBLUE SHIELD ASSIGN. ACCT
0859976000OtherKEYSTONE HMO
0859976000OtherKEYSTONE HMO