Provider Demographics
NPI:1073718599
Name:MAIN LINE FAMILY MEDICINE INC
Entity Type:Organization
Organization Name:MAIN LINE FAMILY MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TETYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZELENSKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-296-2760
Mailing Address - Street 1:63 EASTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19312-1610
Mailing Address - Country:US
Mailing Address - Phone:610-296-2760
Mailing Address - Fax:
Practice Address - Street 1:1450 E BOOT RD
Practice Address - Street 2:STE. 200A
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-5300
Practice Address - Country:US
Practice Address - Phone:610-296-2760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAAPPLYINGMedicaid
=========OtherTAX ID
PAAPPLYINGMedicaid