1417963984 NPI number — MAIN LINE MEDICAL EXERCISE, INC.

Table of content: (NPI 1417963984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417963984 NPI number — MAIN LINE MEDICAL EXERCISE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN LINE MEDICAL EXERCISE, 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:
1417963984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
931 E HAVERFORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRYN MAWR
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19010-3838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-527-7870
Provider Business Mailing Address Fax Number:
610-527-2337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
931 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:
19010-3838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-527-7870
Provider Business Practice Location Address Fax Number:
610-527-2337
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHWAB
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
610-527-7870

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0506820000 . This is a "PERSONAL CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4479578 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 450716 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0506820000 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 655497 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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