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Organization
PMSI COLLEGEVILLE FAMILY PRACTICE
Active
Organization
PMSI COLLEGEVILLE FAMILY PRACTICE
Active
Parent organization
COLLEGEVILLE FAMILY PRACTICE
Other names
COLLEGEVILLE FAMILY PRACTICE
Organization subpart
Yes
Provider details
NPI number
Legal business name
COLLEGEVILLE FAMILY PRACTICE
Authorized official
SHANA M ENOCHS (CREDENTIALING SPECIALIST)
(610) 327-4200
Entity
Organization
Contact information
Practice address
555 SECOND AVENUE, SUITE 300, COLLEGEVILLE, PA 19426
(610) 454-7750
(610) 454-1367
Mailing address
555 SECOND AVENUE, SUITE 300, COLLEGEVILLE, PA 19426
(610) 454-7750
(610) 454-1367
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD046620L
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0045725015
KEYSTONE HMO
PA
01
—
26191
BLUE SHIELD ASSIGN ACCT
PA
Enumeration date
03/19/2007
Last updated
07/14/2016
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