Provider Demographics
NPI:1225268915
Name:MAIN LINE PA ENDOSCOPY ASC, LP
Entity Type:Organization
Organization Name:MAIN LINE PA ENDOSCOPY ASC, LP
Other - Org Name:MAIN LINE ENDOSCOPY CENTER, SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD # L&C
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6187
Mailing Address - Country:US
Mailing Address - Phone:615-240-3820
Mailing Address - Fax:615-234-1720
Practice Address - Street 1:1088 W BALTIMORE PIKE
Practice Address - Street 2:SUITE 2407
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5146
Practice Address - Country:US
Practice Address - Phone:610-545-1338
Practice Address - Fax:610-892-9535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA16001501261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA164211Medicare PIN
PA39C0001135Medicare Oscar/Certification