MEDICARE: MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	2059546	OTHER	PA	AETNA MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2234269001	OTHER	PA	AMERIHEALTH DELAWARE
2	2234269001	OTHER	PA	KEYSTONE HEALTH PCP 65
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	125186900	OTHER	PA	DEPT OF LABOR
6	1551070	OTHER	PA	AMERIHEALTH ADMIN
7	1551070	OTHER	PA	BLUE SHIELD COMP
8	2234269001	OTHER	PA	AMERIHEALTH NEW JERSEY
9	2234269001	OTHER	PA	AMERIHEALTH HMO
10	2234269001	OTHER	PA	BLUE SHIELD ILIN
11	30010759	OTHER	PA	KEYSTONE MERCY
12	1551070	OTHER	PA	BLUE SHIELD
13	2234269001	OTHER	PA	KEYSTONE HEALTH PLAN PCP
14	1551070	OTHER	PA	BLUE SHIELD PA 65
15	2059546	OTHER	PA	AETNA HMO PPO

General Provider Information

NPI Number	:	1194701292
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA

Provider Business Mailing Address
First Line	:	1 W ELM ST
Second Line	:	2ND FLOOR
City	:	CONSHOHOCKEN
State	:	PA
Zip	:	19428-2007
Country	:	US
Telephone Number	:	610-567-6964
Fax Number	:	610-567-6170

Provider Business Practice Location Address
First Line	:	2821 ISLAND AVE
Second Line	:	SUITE D& E
City	:	PHILADELPHIA
State	:	PA
Zip	:	19153-2300
Country	:	US
Telephone Number	:	215-863-6110
Fax Number	:	215-863-6111

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

Provider Enumeration Date	:	12/20/2005
Last Update Date	:	05/09/2008

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1245240985 — KAMRAN TAREEN M.D.
Practice Location Address:

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Practice Location Address:

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Practice Location Address:

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Directions to “MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA ” Practice Location

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