# PMSI BALLY MEDICAL GROUP

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** BALLY MEDICAL GROUP
- **Other names:** BALLY MEDICAL GROUP
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1588788996
- **Legal business name:** BALLY MEDICAL GROUP
- **Authorized official:** SHANA M ENOCHS (CREDENTIALING SPECIALIST)
- **Authorized official phone:** (610) 327-4200

## Contact information

- **Practice address:** 1315 ROUTE 100, BARTP, PA 19504
- **Practice address phone:** (610) 845-2011
- **Practice address fax:** (610) 845-7071
- **Mailing address:** 1315 ROUTE 100, BARTP, PA 19504
- **Mailing address phone:** (610) 845-2011
- **Mailing address fax:** (610) 845-7071

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | OS005855L | PA | Yes |

## Other

- **Enumeration date:** 03/19/2007
- **Last updated:** 07/14/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0020170001 | KEYSTONE HMO | PA |
| 01 | — | 026191 | BLUE SHIELD ASSIGN ACCT | PA |