Provider Demographics
NPI:1790192441
Name:BRYN MAWR MEDICAL SPECIALISTS ASSOCIATION
Entity Type:Organization
Organization Name:BRYN MAWR MEDICAL SPECIALISTS ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:
Authorized Official - Last Name:MILITELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-527-3800
Mailing Address - Street 1:825 OLD LANCASTER RD
Mailing Address - Street 2:STE 320
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3231
Mailing Address - Country:US
Mailing Address - Phone:610-527-3800
Mailing Address - Fax:610-527-0334
Practice Address - Street 1:600 HAVERFORD RD
Practice Address - Street 2:
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041-1139
Practice Address - Country:US
Practice Address - Phone:610-525-2990
Practice Address - Fax:610-525-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-15
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty