Provider Demographics
NPI:1457382053
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:
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 1:1407 RHAWN STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111
Practice Address - Country:US
Practice Address - Phone:215-722-6022
Practice Address - Fax:215-722-6547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101465514 0002Medicaid
PA2457876003OtherIBC#
PA425807OtherAETNA OFFICE #
PA30029001OtherKMHP
PANA1775677OtherBLUE SHIELD
PANA1775677OtherBLUE SHIELD
PA2457876003OtherIBC#