Healthcare Provider Details

I. General information

NPI: 1427246321
Provider Name (Legal Business Name): WESTERN MAIN LINE MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 CREAMERY WAY SUITE 104
EXTON PA
19341-2533
US

IV. Provider business mailing address

460 CREAMERY WAY SUITE 104
EXTON PA
19341-2533
US

V. Phone/Fax

Practice location:
  • Phone: 610-280-7960
  • Fax: 610-280-7962
Mailing address:
  • Phone: 610-280-7960
  • Fax: 610-280-7962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD062918-L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ANDREW B ULICHNEY
Title or Position: PRINCIPAL
Credential: MD
Phone: 610-280-7960