Provider Demographics
NPI:1790796100
Name:MAINLINE MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:MAINLINE MEDICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MIGNOGNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-941-8811
Mailing Address - Street 1:792 GALLITZIN RD
Mailing Address - Street 2:
Mailing Address - City:CRESSON
Mailing Address - State:PA
Mailing Address - Zip Code:16630-2213
Mailing Address - Country:US
Mailing Address - Phone:814-886-8161
Mailing Address - Fax:814-886-2955
Practice Address - Street 1:1400 9TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-2415
Practice Address - Country:US
Practice Address - Phone:814-941-8811
Practice Address - Fax:814-941-8828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
PA010099A291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001746002Medicaid
PA056175OtherHIGHMARK GROUP PROVIDER #
PA056175OtherMEDICARE ID - TYPE UNSPECIFIED PT GROUP #
PA056175OtherHIGHMARK GROUP PROVIDER #