Healthcare Provider Details

I. General information

NPI: 1326565920
Provider Name (Legal Business Name): NAZARETH PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 08/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 HOLME AVE STE 104
PHILA PA
19152-2029
US

IV. Provider business mailing address

1 W ELM ST
CONSHOHOCKEN PA
19428-4108
US

V. Phone/Fax

Practice location:
  • Phone: 215-331-8897
  • Fax: 215-991-2044
Mailing address:
  • Phone: 610-567-6964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: AMIEE BRENNAN
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 610-567-6964