Basic Information
| Provider Information | |||||||||
| NPI: | 1093753873 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY CATHOLIC MEDICAL CENTER OF SOUTHEASTERN PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MERCY FITZGERALD HOSPITAL - PSYCHIATRIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W ELM ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105676603 | ||||||||
| FaxNumber: | 6105676633 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 LANSDOWNE AVE | ||||||||
| Address2: | |||||||||
| City: | DARBY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190231200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102374000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 11/05/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRADLEY | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO & SVP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6105676771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY CATHOLIC MEDICAL CENTER OF SOUTHEASTERN PA | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 0001105000 | 01 | PA | MAGELLAN | OTHER | 12455 | 01 | PA | HEALTHPARTNERS | OTHER | 1007306820001 | 01 | PA | MEDICAL ASSISTANCE | OTHER | 1007306820076 | 01 | PA | MEDICAL ASSISTANCE | OTHER | 1007306820080 | 01 | PA | MEDICAL ASSISTANCE | OTHER | 1007306820100 | 01 | PA | MEDICAL ASSISTANCE | OTHER | 1007306820130 | 01 | PA | MEDICAL ASSISTANCE | OTHER | 1105 | 01 | PA | BLUE CROSS | OTHER | 612766-02 | 01 | PA | AMERICHOICE | OTHER | 60001 | 01 | PA | KMHP | OTHER | 23 | 01 | PA | ELDER CARE | OTHER | 1007306820080 | 01 | PA | CBH | OTHER | 12455 | 01 | PA | SENIOR PARTNERS | OTHER | 39S156 | 01 | PA | MEDICARE ID TYPE UNSPECIFIED | OTHER | PA110 | 01 | PA | QUALMED | OTHER | 1007306820127 | 01 | PA | MEDICAL ASSISTANCE | OTHER | 1007306820002 | 01 | PA | MEDICAL ASSISTANCE | OTHER | 612766-03 | 01 | PA | AMERICHOICE | OTHER |