Provider Demographics
NPI:1932198157
Name:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Entity Type:Organization
Organization Name:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Other - Org Name:MERCY HEALTH ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:HALBERSTADT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-567-6964
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:610-567-6964
Mailing Address - Fax:610-567-6170
Practice Address - Street 1:6323 VINE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-1032
Practice Address - Country:US
Practice Address - Phone:215-748-8303
Practice Address - Fax:215-748-8660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2247379004OtherKEYSTONE HEALTH PLAN EAST
PA36431OtherHEALTH PARTNERS
PADA5351OtherRAILROAD MEDICARE
PA30010755OtherKEYSTONE MERCY HEALTH PLA
PA1007787930163Medicaid
PA1555770OtherBLUE SHIELD
PA61258870002OtherCIGNA
PA36431OtherHEALTH PARTNERS