1790111284 NPI number — MAIN LINE URGENT CARE MEDICAL GROUP PC

Table of content: MRS. REBEKAH ROSE STARK (NPI 1841997095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790111284 NPI number — MAIN LINE URGENT CARE MEDICAL GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN LINE URGENT CARE MEDICAL GROUP 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:
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:
1790111284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2018
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:
410-420-6650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
213 MORTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOLSOM
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19033-3023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-285-9500
Provider Business Practice Location Address Fax Number:
610-237-8701
Provider Enumeration Date:
09/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
REID
Authorized Official First Name:
MAURICE
Authorized Official Middle Name:
N
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
410-569-0044

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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