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General NPI Number Information
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NPI Number | 1457227084
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Entity Type | Organization
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Legal Business Name | MAIN LINE INTEGRATIVE PSYCHIATRY
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Dates
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Enumeration Date | 10/13/2025
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Last Update Date | 10/13/2025
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Provider Practice Location Address
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Address Line | 10 UNION AVE APT 301
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City | BALA CYNWYD
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State | PA
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Zip | 19004-3421
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Country | US
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Telephone | 484-222-0314
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Fax |
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Provider Business Mailing Address
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Address Line | 10 UNION AVE APT 301
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City | BALA CYNWYD
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State | PA
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Zip | 19004-3421
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Country | US
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Telephone | 484-222-0314
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. TIMOTHY ROBERT DEROSA
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Credential | MD
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Telephone | 484-222-0314
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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