Provider Demographics
NPI:1235116047
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: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 1:501 S 54TH ST
Practice Address - Street 2:SUITE 186
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1900
Practice Address - Country:US
Practice Address - Phone:215-748-9530
Practice Address - Fax:215-748-9119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA107787930162Medicaid
PA1783573OtherBLUE SHIELD
PA30026505OtherKEYSTONE MERCY HEALTH PLA
PA5674521OtherAUSHC HMO
PA8496224OtherAUSHC PPO
PA2621808000OtherKEYSTONE HEALTH PLAN EAST
PA30026505OtherKEYSTONE MERCY HEALTH PLA