Basic Information
| Provider Information | |||||||||
| NPI: | 1013997386 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORNANCE PHYSICIAN SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EMERGENCY GROUP FORNANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 820137 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191820137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102702352 | ||||||||
| FaxNumber: | 6102702358 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 POWELL ST | ||||||||
| Address2: | |||||||||
| City: | NORRISTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194013323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102702060 | ||||||||
| FaxNumber: | 6102702652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURNETT-ROBINS | ||||||||
| AuthorizedOfficialFirstName: | VERA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PHYSICIAN BILLING | ||||||||
| AuthorizedOfficialTelephone: | 4846227391 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 50585 | 01 | PA | AETNA | OTHER | CG6886 | 01 | PA | RR MEDICARE | OTHER | 0048792000 | 01 | PA | IBC - PC, KHPE | OTHER | 0048792000 | 01 | PA | AMERIHEALTH/INTERCOUNTY | OTHER | 07237 | 01 | PA | HEALTH PARTNERS | OTHER | 123787 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 40079EM | 01 | PA | KEYSTONE MERCY | OTHER | 00758608 | 01 | PA | AMERICHOICE | OTHER |