Healthcare Provider Details

I. General information

NPI: 1194112573
Provider Name (Legal Business Name): MAIN LINE VASCULAR INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S HENDERSON RD SUITE 304A
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: 215-382-3680
  • Fax:
Mailing address:
  • Phone: 215-382-3680
  • Fax: 215-240-1677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES F MCGUCKIN
Title or Position: CEO
Credential: MD
Phone: 215-382-3680