Provider Demographics
NPI:1477848422
Name:MAIN LINE URGENT CARE MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:MAIN LINE URGENT CARE MEDICAL GROUP, P.C.
Other - Org Name:CARESTAT URGENT CARE CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-569-0044
Mailing Address - Street 1:1505 E CHURCHVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4742
Mailing Address - Country:US
Mailing Address - Phone:410-420-6970
Mailing Address - Fax:410-420-6967
Practice Address - Street 1:1305 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2929
Practice Address - Country:US
Practice Address - Phone:410-420-6970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1891792255OtherNPI REGISTRY
PA6693980001Medicare NSC