Provider Demographics
NPI:1225135585
Name:MAIN LINE HEALTH LABORATORIES
Entity Type:Organization
Organization Name:MAIN LINE HEALTH LABORATORIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
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:484-337-8480
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:
Mailing Address - Fax:
Practice Address - Street 1:240 N RADNOR CHESTER RD
Practice Address - Street 2:SUITE 360
Practice Address - City:RADNOR
Practice Address - State:PA
Practice Address - Zip Code:19087-5170
Practice Address - Country:US
Practice Address - Phone:610-229-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000213291U00000X
PA000242291U00000X
PA000199291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015758270006Medicaid
310260OtherBLUE SHIED
PA0015758270004Medicaid
690006671OtherRAILROAD MEDICARE
6343OtherPERSONAL CHOICE
PA0015758270003Medicaid
001575827-01OtherAMERICHOICE
6343OtherPERSONAL CHOICE