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
StateLicense IDTaxonomies
103T00000X, 207Q00000X, 207R00000X, 207RH0003X, 207T00000X, 207VX0201X, 207X00000X, 2084N0400X, 208C00000X, 208G00000X, 208M00000X, 363L00000X
PA207RE0101X, 207V00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007723500075Medicaid
PA1007723500121Medicaid
PA1007723500075Medicaid
PA037276Medicare ID - Type UnspecifiedINTERNAL MED SPECIALISTS
PA026730Medicare ID - Type UnspecifiedCOLORECTAL
PA050333Medicare ID - Type UnspecifiedPSYCHIATRY
PA440771Medicare ID - Type UnspecifiedMULTI-SPECIALTY
PAW04077Medicare UPIN