Provider Demographics
NPI:1396758033
Name:MERCURY PODIATRY, INC
Entity type:Organization
Organization Name:MERCURY PODIATRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:HALUSKA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:610-874-8431
Mailing Address - Street 1:4201 EDGMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:19015-2315
Mailing Address - Country:US
Mailing Address - Phone:610-874-8431
Mailing Address - Fax:610-874-8288
Practice Address - Street 1:4201 EDGMONT AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-2315
Practice Address - Country:US
Practice Address - Phone:610-874-8431
Practice Address - Fax:610-874-8288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC001693L332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA21283OtherHEALTHPARTNERS
PA00005014350002Medicaid
PAJ88440OtherAMERIHEALTH OF PA
PA088440OtherBLUE SHIELD
PA0581050001Medicare NSC
PA21283OtherHEALTHPARTNERS
PA088440OtherBLUE SHIELD