MEDICARE: MERCY MANAGEMENT OF SEPA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1417946633
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCY MANAGEMENT OF SEPA

Provider Business Mailing Address
First Line	:	1 W ELM ST
Second Line	:	2ND FLOOR
City	:	CONSHOHOCKEN
State	:	PA
Zip	:	19428-2007
Country	:	US
Telephone Number	:	610-567-6964
Fax Number	:	610-567-6170

Provider Business Practice Location Address
First Line	:	501 S 54TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-1900
Country	:	US
Telephone Number	:	215-748-9872
Fax Number	:	214-748-9869

Authorized Official
Title or Position	:	CFO
Name	:	MR. DON HALBERSTADT
Credential	:
Telephone Number	:	610-567-6964

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	03/11/2008

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Directions to “MERCY MANAGEMENT OF SEPA ” Practice Location

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