Provider Demographics
NPI: | 1922077643 |
---|---|
Name: | MAIN LINE HEALTHCARE |
Entity Type: | Organization |
Organization Name: | MAIN LINE HEALTHCARE |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MANAGER |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | JENNA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | FOOTE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 484-337-1667 |
Mailing Address - Street 1: | 3803 W CHESTER PIKE |
Mailing Address - Street 2: | H BLDG SUITE 160 |
Mailing Address - City: | NEWTOWN SQUARE |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 19073-2333 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 484-337-1585 |
Mailing Address - Fax: | 484-337-1410 |
Practice Address - Street 1: | 3803 WEST CHESTER PIKE |
Practice Address - Street 2: | H BLDG SUITE 160 |
Practice Address - City: | NEWTOWN SQUARE |
Practice Address - State: | PA |
Practice Address - Zip Code: | 19073-2333 |
Practice Address - Country: | US |
Practice Address - Phone: | 484-337-1585 |
Practice Address - Fax: | 484-337-1410 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-03-15 |
Last Update Date: | 2021-04-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
103T00000X, 207Q00000X, 207R00000X, 207RH0003X, 207T00000X, 207VX0201X, 207X00000X, 2084N0400X, 208C00000X, 208G00000X, 208M00000X, 363L00000X | ||
PA | 207RE0101X, 207V00000X, 208600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207VX0201X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | Group - Multi-Specialty |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208C00000X | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | Group - Multi-Specialty | |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 1007723500075 | Medicaid | |
PA | 1007723500121 | Medicaid | |
PA | 1007723500075 | Medicaid | |
PA | 037276 | Medicare ID - Type Unspecified | INTERNAL MED SPECIALISTS |
PA | 026730 | Medicare ID - Type Unspecified | COLORECTAL |
PA | 050333 | Medicare ID - Type Unspecified | PSYCHIATRY |
PA | 440771 | Medicare ID - Type Unspecified | MULTI-SPECIALTY |
PA | W04077 | Medicare UPIN |