Provider Demographics
NPI:1316580178
Name:OLINE TREE MEDICAL PRACTICE
Entity Type:Organization
Organization Name:OLINE TREE MEDICAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-805-2647
Mailing Address - Street 1:270 WINDERMERE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:PA
Mailing Address - Zip Code:19050-1154
Mailing Address - Country:US
Mailing Address - Phone:215-805-2647
Mailing Address - Fax:215-245-4827
Practice Address - Street 1:802 BURMONT ROAD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-4413
Practice Address - Country:US
Practice Address - Phone:215-805-2647
Practice Address - Fax:215-245-4827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty