Basic Information
| Provider Information | |||||||||
| NPI: | 1588694111 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 GILL ST | ||||||||
| Address2: | STE 3000 | ||||||||
| City: | WOBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018011728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819374522 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 LANSDOWNE AVE | ||||||||
| Address2: | |||||||||
| City: | DARBY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190231200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102374000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6105675148 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY HEALTH SYSTEM | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100778793 | 05 | PA | MEDICAID |