Provider Demographics
NPI:1194701292
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 SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG;AS
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:610-567-6170
Practice Address - Street 1:2821 ISLAND AVE
Practice Address - Street 2:SUITE D& E
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19153-2300
Practice Address - Country:US
Practice Address - Phone:215-863-6110
Practice Address - Fax:215-863-6111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2234269001OtherAMERIHEALTH DELAWARE
PA2234269001OtherKEYSTONE HEALTH PCP 65
PA100778793 0152Medicaid
PA125186900OtherDEPT OF LABOR
PA2059546OtherAETNA MEDICARE
PA1551070OtherAMERIHEALTH ADMIN
PA1551070OtherBLUE SHIELD COMP
PA2234269001OtherAMERIHEALTH NEW JERSEY
PA2234269001OtherAMERIHEALTH HMO
PA2234269001OtherBLUE SHIELD ILIN
PA30010759OtherKEYSTONE MERCY
PA1551070OtherBLUE SHIELD
PA2234269001OtherKEYSTONE HEALTH PLAN PCP
PA1551070OtherBLUE SHIELD PA 65
PA2059546OtherAETNA HMO PPO
PA2059546OtherAETNA MEDICARE
PA2234269001OtherAMERIHEALTH HMO