Healthcare Provider Details

I. General information

NPI: 1043233000
Provider Name (Legal Business Name): MERCY MANAGEMENT OF SEPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S 54TH ST
PHILADELPHIA PA
19143-1900
US

IV. Provider business mailing address

1 W ELM ST 2ND FLOOR
CONSHOHOCKEN PA
19428-2007
US

V. Phone/Fax

Practice location:
  • Phone: 215-748-9872
  • Fax: 215-748-9869
Mailing address:
  • Phone: 610-567-6964
  • Fax: 610-567-6170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN003282
License Number StatePA

VIII. Authorized Official

Name: MR. DOUGLAS C SMITH
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 610-567-6964