Provider Demographics
NPI:1831231679
Name:PENNCARE - ROYERSFORD MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:PENNCARE - ROYERSFORD MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-625-2990
Mailing Address - Street 1:5810 NANCY RIDGE DR
Mailing Address - Street 2:100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 W LINFIELD RD
Practice Address - Street 2:
Practice Address - City:LIMERICK
Practice Address - State:PA
Practice Address - Zip Code:19468-4278
Practice Address - Country:US
Practice Address - Phone:610-495-2650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-12
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006549L332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site