Provider Demographics
NPI:1952759094
Name:MERCY NEIGHBORHOOD MINISTRIES OF PHILADELPHIA, INC
Entity Type:Organization
Organization Name:MERCY NEIGHBORHOOD MINISTRIES OF PHILADELPHIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVOST
Authorized Official - Suffix:
Authorized Official - Credentials:RSM
Authorized Official - Phone:215-227-4393
Mailing Address - Street 1:1939 W VENANGO ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-3919
Mailing Address - Country:US
Mailing Address - Phone:215-227-4393
Mailing Address - Fax:215-227-4394
Practice Address - Street 1:1939 W VENANGO ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-3919
Practice Address - Country:US
Practice Address - Phone:215-227-4393
Practice Address - Fax:215-227-4394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA314250 - REGULAR261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102263747Medicaid