Provider Demographics
NPI:1093357923
Name:MAIN LINE WELLNESS LLC
Entity Type:Organization
Organization Name:MAIN LINE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:LERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-337-3111
Mailing Address - Street 1:700 S HENDERSON RD STE 308C
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-4206
Mailing Address - Country:US
Mailing Address - Phone:610-337-3111
Mailing Address - Fax:610-233-1272
Practice Address - Street 1:700 S HENDERSON RD STE 308C
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-4206
Practice Address - Country:US
Practice Address - Phone:610-337-3111
Practice Address - Fax:610-233-1272
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROY M LERMAN MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1234567OtherSTARTING CREDENTIALING PROCESS