Provider Demographics
NPI:1023439825
Name:FORNANCE PHYSICIAN SERVICES, INC
Entity type:Organization
Organization Name:FORNANCE PHYSICIAN SERVICES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:CANDIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-456-4694
Mailing Address - Street 1:100 MARKET ST STE 300
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-4927
Mailing Address - Country:US
Mailing Address - Phone:484-622-6400
Mailing Address - Fax:484-622-6403
Practice Address - Street 1:100 MARKET ST
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-4927
Practice Address - Country:US
Practice Address - Phone:484-622-6400
Practice Address - Fax:484-622-6403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-20
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty