Provider Demographics
NPI:1356586028
Name:MAIN LINE PLASTIC SURGERY&LASER ASSOCIATES
Entity type:Organization
Organization Name:MAIN LINE PLASTIC SURGERY&LASER ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:GLUNK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-354-8800
Mailing Address - Street 1:216 MALL BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-2923
Mailing Address - Country:US
Mailing Address - Phone:610-354-8800
Mailing Address - Fax:
Practice Address - Street 1:216 MALL BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-2923
Practice Address - Country:US
Practice Address - Phone:610-354-8800
Practice Address - Fax:610-354-9066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA15511501261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical