Provider Demographics
NPI:1053394122
Name:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Entity type:Organization
Organization Name:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-464-0724
Mailing Address - Street 1:PO BOX 827176
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-7176
Mailing Address - Country:US
Mailing Address - Phone:717-464-0724
Mailing Address - Fax:
Practice Address - Street 1:1500 LANSDOWNE AVE
Practice Address - Street 2:
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-1200
Practice Address - Country:US
Practice Address - Phone:610-237-3616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY MANAGEMENT OF SOUTHEASTERN PENNSYLVANIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-22
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA050443416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007787930103Medicaid
PA1147955OtherKEYSTONE MERCY
PA1007787930103Medicaid