Provider Demographics
NPI:1194707380
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:CFO
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:610-567-6170
Practice Address - Street 1:1501 LANSDOWNE AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-1333
Practice Address - Country:US
Practice Address - Phone:610-534-6170
Practice Address - Fax:610-534-6159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3955657OtherAETNA
PA2414129000OtherKHPE
PA5746424OtherCIGNA
PA1007787930153Medicaid
PA30023892OtherKEYSTONE MECY
PA1738463OtherBLUE SHIELD
PADA5351OtherRAILROAD MEDICARE
PA30023892OtherKEYSTONE MECY