Provider Demographics
NPI:1831146919
Name:FORNANCE PHYSICIAN SERVICES, INC.
Entity Type:Organization
Organization Name:FORNANCE PHYSICIAN SERVICES, INC.
Other - Org Name:KING OF PRUSSIA FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-622-7371
Mailing Address - Street 1:PO BOX 789967
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-9967
Mailing Address - Country:US
Mailing Address - Phone:484-622-7395
Mailing Address - Fax:484-622-7399
Practice Address - Street 1:210 MALL BLVD STE 102
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-3260
Practice Address - Country:US
Practice Address - Phone:610-265-0726
Practice Address - Fax:610-265-3132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2018-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1112971OtherKEYSTONE MERCY
PACI4349OtherRRM
PA0418121001OtherIBC - PC/KHPE
PA1738323Medicaid
PA26575OtherHEALTH PARTNERS SITE #
PA5242713OtherAETNA PPO
PA0418121001OtherAMERIHEALTH/INTERCOUNTY
PA639587OtherHIGHMARK BLUE SHIELD
PA2047128OtherAETNA HMO
PA6522623OtherCIGNA HMO/PPO
PA1112971OtherKEYSTONE MERCY