1023115078 NPI number — MAIN LINE PA ENDOSCOPY ASC LP

Table of content: (NPI 1023115078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023115078 NPI number — MAIN LINE PA ENDOSCOPY ASC LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN LINE PA ENDOSCOPY ASC LP
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:
MAIN LINE ENDOSCOPY CENTER MALVERN
Provider Other Organization Name Type Code:
3
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:
1023115078
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1A BURTON HILLS BLVD # L&C
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37215-6153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-240-3820
Provider Business Mailing Address Fax Number:
615-234-1720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 WEST CENTRAL AVE
Provider Second Line Business Practice Location Address:
LOWER LEVEL
Provider Business Practice Location Address City Name:
MALVERN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19355-3219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-644-7274
Provider Business Practice Location Address Fax Number:
610-644-7276
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SNODGRASS
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-665-1283

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  15801501 , 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: P00478537 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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