MEDICARE: MERCY MANAGEMENT OF SEPA

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	207VG0400X	Gynecology Physician	MD039162	PA

General Provider Information

NPI Number	:	1295758233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCY MANAGEMENT OF SEPA

Provider Business Mailing Address
First Line	:	1 W ELM ST
Second Line	:	2 ND 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	:	2ND FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19153-2300
Country	:	US
Telephone Number	:	215-863-6141
Fax Number	:	215-863-6102

Authorized Official
Title or Position	:	V P FINANCIAL SERVICES
Name	:	DR. DOUGLAS C SMITH
Credential	:
Telephone Number	:	610-567-6964

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	08/22/2020

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