Provider Demographics
NPI:1346443496
Name:MAIN LINE CENTER FOR SKIN SURGERY, INC
Entity Type:Organization
Organization Name:MAIN LINE CENTER FOR SKIN SURGERY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:R
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:484-343-8751
Mailing Address - Street 1:306 GYPSY LN
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-1103
Mailing Address - Country:US
Mailing Address - Phone:484-343-8751
Mailing Address - Fax:
Practice Address - Street 1:822 MONTGOMERY AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:NARBERTH
Practice Address - State:PA
Practice Address - Zip Code:19072-1937
Practice Address - Country:US
Practice Address - Phone:484-343-8751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-047761-L207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty