Basic Information
| Provider Information | |||||||||
| NPI: | 1720495583 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY LIFE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W ELM ST | ||||||||
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| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194284108 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1930 S BROAD ST | ||||||||
| Address2: | UNIT 3 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191452328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153394563 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2014 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | HILKER | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REGIONAL PRACTICE | ||||||||
| AuthorizedOfficialTelephone: | 6105675529 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.