Healthcare Provider Details

I. General information

NPI: 1437649985
Provider Name (Legal Business Name): MAIN LINE HEALTH INTEGRATIVE AND FUNCTIONAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3803 W CHESTER PIKE STE 160
NEWTOWN SQUARE PA
19073
US

IV. Provider business mailing address

3803 W CHESTER PIKE STE 160
NEWTOWN SQUARE PA
19073-2336
US

V. Phone/Fax

Practice location:
  • Phone: 484-337-1585
  • Fax: 484-337-1410
Mailing address:
  • Phone: 484-337-1585
  • Fax: 484-337-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDREA GILBERT
Title or Position: PRESIDENT
Credential:
Phone: 484-337-3570