Provider Demographics
| NPI: | 1083777239 |
|---|---|
| Name: | MAIN LINE AFFILIATES |
| Entity Type: | Organization |
| Organization Name: | MAIN LINE AFFILIATES |
| Other - Org Name: | MAIN LINE BEHAVIORAL HEALTH AFFILIATES |
| Other - Org Type: | Other Name |
| Authorized Official - Title/Position: | EXEC. VP & CFO |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | MICHAEL |
| Authorized Official - Middle Name: | J |
| Authorized Official - Last Name: | BUONGIORNO |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 484-337-8481 |
| Mailing Address - Street 1: | 950 E HAVERFORD RD |
| Mailing Address - Street 2: | SUITE 110 |
| Mailing Address - City: | BRYN MAWR |
| Mailing Address - State: | PA |
| Mailing Address - Zip Code: | 19010-3850 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 610-526-8480 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 1 RADNOR CORPORATE CTR |
| Practice Address - Street 2: | SUITE 400 |
| Practice Address - City: | RADNOR |
| Practice Address - State: | PA |
| Practice Address - Zip Code: | 19087-4515 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 610-254-1450 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-12-19 |
| Last Update Date: | 2016-05-18 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 101YA0400X, 103G00000X, 103T00000X, 103TC0700X, 103TR0400X, 2084P0800X, 2084P0802X, 2084P0804X, 261QM0850X | ||
| PA | 237078 | 261QR0405X |
| PA | 151081 | 261QR0405X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 103G00000X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | Group - Multi-Specialty | |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 103TR0400X | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation | Group - Multi-Specialty |
| No | 2084P0802X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | Group - Multi-Specialty |
| No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Multi-Specialty |
| No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | Group - Multi-Specialty |
| No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| 293195 | Other | VALUEOPTIONS - MLA | |
| 471443000 | Other | MAGELLAN - MLA | |
| 2089835 | Other | CIGNA - CAD EXTON | |
| 2983830 | Other | AETNA HMO - CAD DREX HILL | |
| 2089834 | Other | CIGNA - CAD DREXEL HILL | |
| 231200000 | Other | MAGELLAN - CAD EXTON | |
| 280110000 | Other | MAGELLAN - CAD DREXEL HIL | |
| 0664704000 | Other | IBC - BMR PSYCH ASSOC | |
| PA | 1007726370011 | Medicaid | |
| 101825 | Other | UNITED - CAD ADOLESCENT | |
| 2317419000 | Other | IBC - MLA | |
| 101823 | Other | UNITED - CAD - ADULT PHP | |
| 101824 | Other | UNITED - CAD ADULT IOP | |
| 2983910 | Other | AETNA HMO - CAD EXTON | |
| 0470009 | Other | AETNA HMO - BMR PSYCH | |
| 7985197 | Other | AETNA PPO - MLA | |
| 2983910 | Other | AETNA HMO - CAD EXTON |
