Provider Demographics
NPI:1891771994
Name:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Entity Type:Organization
Organization Name:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Other - Org Name:MMS-MERCY ORTHPAEDICS ASSOCIATES
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 1:501 S 54TH ST
Practice Address - Street 2:SUITE 28
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1900
Practice Address - Country:US
Practice Address - Phone:215-748-9822
Practice Address - Fax:215-748-9717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD047458207XS0114X
PAMD042497207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007787930159Medicaid
PA1251834000OtherDEPARTMENT OF LABOR
PA2957200OtherAETNA HMO
PA30010804OtherKERYSTONE MERCY HEALTH PL
PA1544388OtherBLUE SHIELD
PA2228682000OtherKEYSTONE HEALTH PLAN EAST
PA33316OtherHEALTH PARTNERS
PADA5351Medicare PIN
PA2228682000OtherKEYSTONE HEALTH PLAN EAST