MEDICARE: DR. ELLEN DELEA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QG0300X	Geriatric Medicine (Family Medicine) Physician	MD422949	PA
2	207Q00000X	Family Medicine Physician	MD422949	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	232359401	OTHER	PA	MAIN LINE HEALTHCARE

General Provider Information

NPI Number	:	1467431635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN DELEA MD

Provider Business Mailing Address
First Line	:	111 ELWYN RD
Second Line	:	MEDICAL SUITE
City	:	ELWYN
State	:	PA
Zip	:	19063-4622
Country	:	US
Telephone Number	:	610-891-7317
Fax Number	:	610-891-2111

Provider Business Practice Location Address
First Line	:	111 ELWYN RD
Second Line	:	MEDICAL SUITE
City	:	ELWYN
State	:	PA
Zip	:	19063-4622
Country	:	US
Telephone Number	:	610-891-7317
Fax Number	:	610-891-2111

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2006
Last Update Date	:	06/01/2009

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