Provider Demographics
NPI:1770566309
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 SVCS
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:610-567-6964
Practice Address - Street 1:5070 PARKSIDE AVE
Practice Address - Street 2:SUITE 50100
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-4747
Practice Address - Country:US
Practice Address - Phone:215-473-4700
Practice Address - Fax:215-473-1515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007787930156Medicaid
PA125183500OtherDEPARTMENT OF LABOR
PA1549288OtherBLUE SHIELD
PA30010782OtherKEYSTONE MERCY HEALTH PLA
PA0019352OtherAETNA HMO
PA5253340OtherAETNA PPO
PA2233322001OtherKEYSTONE HEALTH PLAN EAST
PA1007787930156Medicaid
PADA5351Medicare PIN