1568824050 NPI number — MAINLINE URGENT CARE MEDICAL GROUP, P.C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568824050 NPI number — MAINLINE URGENT CARE MEDICAL GROUP, P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAINLINE URGENT CARE MEDICAL GROUP, P.C
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:
1568824050
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1505 E CHURCHVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEL AIR
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21014-4742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-420-6970
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
89 E FORREST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREWSBURY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17361-1402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-482-4949
Provider Business Practice Location Address Fax Number:
484-454-3427
Provider Enumeration Date:
03/23/2016

Additional Information

Authorized Official

Authorized Official Last Name:
REID
Authorized Official First Name:
MAURICE
Authorized Official Middle Name:
NATHANIEL
Authorized Official Title or Position:
CEO/MD
Authorized Official Telephone Number:
410-420-6970

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  MD442240 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102867981-0003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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