Healthcare Provider Details

I. General information

NPI: 1588788996
Provider Name (Legal Business Name): PMSI BALLY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 ROUTE 100
BARTP PA
19504
US

IV. Provider business mailing address

1315 ROUTE 100
BARTP PA
19504
US

V. Phone/Fax

Practice location:
  • Phone: 610-845-2011
  • Fax: 610-845-7071
Mailing address:
  • Phone: 610-845-2011
  • Fax: 610-845-7071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS005855L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0020170001
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerKEYSTONE HMO
# 2
Identifier026191
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD ASSIGN ACCT

VIII. Authorized Official

Name: SHANA M ENOCHS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 610-327-4200