Provider Demographics
NPI:1942324330
Name:PMSI COLLEGEVILLE FAMILY PRACTICE
Entity Type:Organization
Organization Name:PMSI COLLEGEVILLE FAMILY PRACTICE
Other - Org Name:COLLEGEVILLE FAMILY PRACTICE
Other - Org Type:Doing Business As
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 1:555 SECOND AVENUE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426
Mailing Address - Country:US
Mailing Address - Phone:610-454-7750
Mailing Address - Fax:610-454-1367
Practice Address - Street 1:555 SECOND AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426
Practice Address - Country:US
Practice Address - Phone:610-454-7750
Practice Address - Fax:610-454-1367
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLLEGEVILLE FAMILY PRACTICE
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
PAMD046620L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA26191OtherBLUE SHIELD ASSIGN ACCT
PA0045725015OtherKEYSTONE HMO
PA026191D8PMedicare PIN