Provider Demographics
NPI:1760415913
Name:MAIN LINE MEDICAL GROUP LTD
Entity Type:Organization
Organization Name:MAIN LINE MEDICAL GROUP LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:610-664-2951
Mailing Address - Street 1:857 MONTGOMERY AVE
Mailing Address - Street 2:
Mailing Address - City:NARBERTH
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1541
Mailing Address - Country:US
Mailing Address - Phone:610-664-2951
Mailing Address - Fax:610-664-2131
Practice Address - Street 1:857 MONTGOMERY AVE
Practice Address - Street 2:
Practice Address - City:NARBERTH
Practice Address - State:PA
Practice Address - Zip Code:19072-1541
Practice Address - Country:US
Practice Address - Phone:610-664-2951
Practice Address - Fax:610-664-2131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ052445Medicare PIN
PA054484Medicare ID - Type Unspecified