Provider Demographics
NPI:1538190137
Name:NAZARETH PHYSICIAN SERVICES INC
Entity type:Organization
Organization Name:NAZARETH PHYSICIAN SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WAJDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-335-6614
Mailing Address - Street 1:1 W ELM ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-4108
Mailing Address - Country:US
Mailing Address - Phone:610-567-6967
Mailing Address - Fax:
Practice Address - Street 1:2601 HOLME AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2007
Practice Address - Country:US
Practice Address - Phone:215-350-7417
Practice Address - Fax:215-335-6303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2457876000OtherIBC#
PA101465514 0001Medicaid
PANA1775677OtherHIGHMARK BLUE SHIELD
PA425807OtherAETNA OFFICE #
PA425807OtherAETNA OFFICE #
PANA1775677OtherHIGHMARK BLUE SHIELD