MEDICARE: NAZARETH PHYSICIAN SERVICES INC

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	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2457876003	OTHER	PA	IBC#
3	425807	OTHER	PA	AETNA OFFICE #
4	30029001	OTHER	PA	KMHP
5	NA1775677	OTHER	PA	BLUE SHIELD

General Provider Information

NPI Number	:	1457382053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NAZARETH PHYSICIAN SERVICES INC

Provider Business Mailing Address
First Line	:	1 W ELM ST
Second Line	:
City	:	CONSHOHOCKEN
State	:	PA
Zip	:	19428-2007
Country	:	US
Telephone Number	:	610-567-6967
Fax Number	:	610-567-6170

Provider Business Practice Location Address
First Line	:	1407 RHAWN STREET
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19111
Country	:	US
Telephone Number	:	215-722-6022
Fax Number	:	215-722-6547

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. JOHN J KIRBY
Credential	:
Telephone Number	:	215-335-6614

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	05/08/2008

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