Healthcare Provider Details

I. General information

NPI: 1215346879
Provider Name (Legal Business Name): MAINLINE BODYBRAIN&SPINE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 CONWAY AVE
NARBERTH PA
19072-2202
US

IV. Provider business mailing address

118 CONWAY AVE
NARBERTH PA
19072-2202
US

V. Phone/Fax

Practice location:
  • Phone: 215-284-0509
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOS015314
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License NumberOS015314
License Number StatePA

VIII. Authorized Official

Name: DR. GINA MARIA BENAQUISTA DESIPIO
Title or Position: PRESIDENT
Credential: D.O.
Phone: 215-284-0509