Healthcare Provider Details

I. General information

NPI: 1568992295
Provider Name (Legal Business Name): MINIMALLY INVASIVE CARE INSTITUTE OF MAIN LINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S HENDERSON RD STE 225
KING OF PRUSSIA PA
19406-3530
US

IV. Provider business mailing address

700 S HENDERSON RD STE 225
KING OF PRUSSIA PA
19406-3530
US

V. Phone/Fax

Practice location:
  • Phone: 484-808-5220
  • Fax:
Mailing address:
  • Phone: 484-808-5220
  • Fax: 484-679-1821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JAMES MCGUCKIN
Title or Position: CEO
Credential: MD
Phone: 484-808-5220