Healthcare Provider Details

I. General information

NPI: 1194701292
Provider Name (Legal Business Name): MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 ISLAND AVE SUITE D& E
PHILADELPHIA PA
19153-2300
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 215-863-6110
  • Fax: 215-863-6111
Mailing address:
  • Phone: 610-567-6964
  • Fax: 610-567-6170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUG;AS C SMITH
Title or Position: VP FINANCIAL SERVICES
Credential:
Phone: 610-567-6964