1699016147 NPI number — MAIN LINE INSTITUTE OF PLASTIC SURGERY INC

Table of content: MELITA CLARESA WILSON- PRIMUS PMHNP-BC (NPI 1063118123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699016147 NPI number — MAIN LINE INSTITUTE OF PLASTIC SURGERY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN LINE INSTITUTE OF PLASTIC SURGERY INC
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:
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:
1699016147
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E LANCASTER AVE
Provider Second Line Business Mailing Address:
MOBE #660
Provider Business Mailing Address City Name:
WYNNEWOOD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19096-3450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-896-6666
Provider Business Mailing Address Fax Number:
610-896-6669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 E LANCASTER AVE
Provider Second Line Business Practice Location Address:
MOBE #660
Provider Business Practice Location Address City Name:
WYNNEWOOD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19096-3450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-896-6666
Provider Business Practice Location Address Fax Number:
610-896-6669
Provider Enumeration Date:
03/08/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HOFFMAN
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
SAMUEL
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
610-896-6666

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  MD422651 , 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)





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