Healthcare Provider Details

I. General information

NPI: 1053557082
Provider Name (Legal Business Name): MAIN LINE GASTROENTEROLOGY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2008
Last Update Date: 12/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W LANCASTER AVE PAOLI MEDICAL BUILDING, SUITE 332
PAOLI PA
19301-1763
US

IV. Provider business mailing address

255 W LANCASTER AVE PAOLI MEDICAL BUILDING, SUITE 332
PAOLI PA
19301-1763
US

V. Phone/Fax

Practice location:
  • Phone: 610-644-6755
  • Fax: 610-647-2063
Mailing address:
  • Phone: 610-644-6755
  • Fax: 610-647-2063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: ELLIE SUDER
Title or Position: BILLING MANAGER
Credential:
Phone: 215-723-2333