Healthcare Provider Details

I. General information

NPI: 1619492394
Provider Name (Legal Business Name): NAZARETH PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 HOLME AVE OFC BUILDING
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: 215-335-3972
  • Fax: 215-335-3784
Mailing address:
  • Phone: 610-567-6964
  • Fax: 610-567-5420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

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