Basic Information
Provider Information | |||||||||
NPI: | 1730173550 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY CATHOLIC MEDICAL CENTER OF SOUTHEASTERN PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MERCY FITZGERALD HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 41 UNIVERSITY DR STE 106 | ||||||||
Address2: |   | ||||||||
City: | NEWTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 189401873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1500 LANSDOWNE AVE | ||||||||
Address2: |   | ||||||||
City: | DARBY | ||||||||
State: | PA | ||||||||
PostalCode: | 190231200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6102374000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2005 | ||||||||
LastUpdateDate: | 04/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARUSO | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2157102651 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MERCY CATHOLIC MEDICAL CENTER OF SOUTHEASTERN PA | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 12455 | 01 | PA | HEALTH PARTNERS | OTHER | 0001105000 | 01 | PA | KEYSTONE EAST | OTHER | 0061276602 | 01 | PA | AMERICHOICE | OTHER | 60001 | 01 | PA | KMHP | OTHER | 0001105000 | 01 | PA | IBC | OTHER | 0001439 | 01 | PA | AETNA | OTHER | 100730682 | 05 | PA |   | MEDICAID | 390156 | 01 | PA | MEDICARE ID TYPE UNSPECIFIED | OTHER |