1083777239 NPI number — MAIN LINE AFFILIATES

Table of content: (NPI 1083777239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083777239 NPI number — MAIN LINE AFFILIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN LINE AFFILIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083777239
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 E HAVERFORD RD
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
BRYN MAWR
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19010-3850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-526-8480
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 RADNOR CORPORATE CTR
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
RADNOR
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19087-4515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-254-1450
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUONGIORNO
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
EXEC. VP & CFO
Authorized Official Telephone Number:
484-337-8481

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X , with the licence number: 237078 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X , with the licence number: 151081 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0802X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 293195 . This is a "VALUEOPTIONS - MLA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 471443000 . This is a "MAGELLAN - MLA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2089835 . This is a "CIGNA - CAD EXTON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2983830 . This is a "AETNA HMO - CAD DREX HILL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2089834 . This is a "CIGNA - CAD DREXEL HILL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 231200000 . This is a "MAGELLAN - CAD EXTON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 280110000 . This is a "MAGELLAN - CAD DREXEL HIL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0664704000 . This is a "IBC - BMR PSYCH ASSOC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1007726370011 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101825 . This is a "UNITED - CAD ADOLESCENT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2317419000 . This is a "IBC - MLA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 101823 . This is a "UNITED - CAD - ADULT PHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 101824 . This is a "UNITED - CAD ADULT IOP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2983910 . This is a "AETNA HMO - CAD EXTON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0470009 . This is a "AETNA HMO - BMR PSYCH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7985197 . This is a "AETNA PPO - MLA" identifier . This identifiers is of the category "OTHER".




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