1366279390 NPI number — BRYN MAWR PERSONALIZED PRIMARY CARE PC

Table of content: (NPI 1366279390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366279390 NPI number — BRYN MAWR PERSONALIZED PRIMARY CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRYN MAWR PERSONALIZED PRIMARY CARE PC
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:
1366279390
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 PERIWINKLE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYNNEWOOD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19096-1647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-919-4542
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
937 E HAVERFORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRYN MAWR
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19010-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-919-4542
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/16/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OLER
Authorized Official First Name:
ALLISON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
484-919-4542

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 062367-L . This is a "STATE LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 456438 . This is a "STATE LICENSE DR MEAGHAN HENRICI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 459217 . This is a "STATE LICENSE DR LEILA OBEID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".