Provider Demographics
NPI:1356377550
Name:NAZARETH PHYSICIAN SERVICES INC
Entity type:Organization
Organization Name:NAZARETH PHYSICIAN SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-335-6614
Mailing Address - Street 1:1 W ELM ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2007
Mailing Address - Country:US
Mailing Address - Phone:610-567-6967
Mailing Address - Fax:610-567-6170
Practice Address - Street 1:7044 TORRESDALE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19135-1915
Practice Address - Country:US
Practice Address - Phone:215-332-7772
Practice Address - Fax:215-332-2547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA658619OtherAETNA OFFICE #
PA101465514 0003Medicaid
PA2457876002OtherIBC#
PANA1775677OtherHIGHMARK BLUE SHIELD
PADE5402Medicare PIN
PA095918Medicare PIN