MEDICARE: MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA

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	2455345001	OTHER	PA	KEYSTONE HEALTH PLAN EAST
3	37229	OTHER	PA	HEALTHPARTNERS
4	30035743	OTHER	PA	KEYSTONE MERCY HEALTHPLAN
5	1147948	OTHER	PA	AETNA HMO PPO
6	1772599	OTHER	PA	BLUE SHIELD

General Provider Information

NPI Number	:	1598755340
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA

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	:	831 PROVIDENCE RD
Second Line	:
City	:	SECANE
State	:	PA
Zip	:	19018-2921
Country	:	US
Telephone Number	:	610-934-1234
Fax Number	:	610-934-4811

Authorized Official
Title or Position	:	VP FINANCIAL SERVICES
Name	:	MR. DOUGLAS C SMITH
Credential	:
Telephone Number	:	610-567-6964

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	03/20/2008

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Directions to “MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA ” Practice Location

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