Provider Demographics
NPI:1396721494
Name:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Entity type:Organization
Organization Name:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1900
Practice Address - Country:US
Practice Address - Phone:215-748-9707
Practice Address - Fax:215-748-9708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100778793 0157Medicaid
PA1543646OtherBLUE SHIELD COMP
PA1543646OtherBLUE SHIELD PA PR
PA1543648OtherAMERIHEALTH ADMIN
PA2228313000OtherAMERIHEALTH DELAWARE
PA2228313000OtherBLUE SHIELD LLIN
PA33695OtherHEALTH PARTNERS SENIOR
PA1543646OtherBLUE SHIELD
PA2228313000OtherKEYSTONE 65 SPECIAL
PA2507496OtherAETNA MEDICARE HMO
PA2228313000OtherAMERIHEALTH HMO
PA2228313000OtherAMERIHEALTH NEW JERSEY
PA2228313000OtherKEYSTONE HEALTH PLAN
PA33695OtherHEALTH PARTNERS
PA125183600OtherDEPT OF LABOR
PA2507496OtherAETNA HMO SPECIALIST
PA1543646OtherBLUE SHIELD PA 65
PA7770198OtherAETNA OTHER
PAG000668600OtherAMERICHOICE
PA1543646OtherBLUE SHIELD PA 65
PA2228313000OtherKEYSTONE 65 SPECIAL