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
3	DA5351	OTHER	PA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2247379004	OTHER	PA	KEYSTONE HEALTH PLAN EAST
2	36431	OTHER	PA	HEALTH PARTNERS
4	30010755	OTHER	PA	KEYSTONE MERCY HEALTH PLA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	1555770	OTHER	PA	BLUE SHIELD
7	61258870002	OTHER	PA	CIGNA

General Provider Information

NPI Number	:	1932198157
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	:
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	:	6323 VINE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19139-1032
Country	:	US
Telephone Number	:	215-748-8303
Fax Number	:	215-748-8660

Authorized Official
Title or Position	:	CFO
Name	:	MR. DON HALBERSTADT
Credential	:
Telephone Number	:	610-567-6964

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	07/19/2007

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Directions to “MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA ” Practice Location

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