Basic Information
| Provider Information | |||||||||
| NPI: | 1346285376 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MANAGEMENT OF SE PA | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MERCY FITZGERALD CRNA SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 827675 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191827675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564237700 | ||||||||
| FaxNumber: | 8564230823 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 LANSDOWNE AVENUE | ||||||||
| Address2: | |||||||||
| City: | DARBY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102374000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAMERON | ||||||||
| AuthorizedOfficialFirstName: | GINA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6102374280 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY MANAGEMENT OF SE PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1007787930164 | 05 | PA | MEDICAID | DB6047 | 01 | RAILROAD MEDICARE GROUP | OTHER |