Provider Demographics
NPI:1144540337
Name:PHOENIXVILLE MEDICAL GROUP
Entity type:Organization
Organization Name:PHOENIXVILLE MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMMUNICATIONS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-327-4200
Mailing Address - Street 1:1610 MEDICAL DRIVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464
Mailing Address - Country:US
Mailing Address - Phone:610-327-4200
Mailing Address - Fax:610-327-8160
Practice Address - Street 1:500 GAY STREET
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460
Practice Address - Country:US
Practice Address - Phone:610-935-7500
Practice Address - Fax:610-935-4338
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POTTSTOWN MEDICAL SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-10
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024972E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007964850006Medicaid
PA026191OtherBLUE SHIELD
PA0007964850006Medicaid