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General NPI Number Information
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NPI Number | 1538937123
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Entity Type | Organization
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Legal Business Name | MAIN LINE RETINA
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Dates
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Enumeration Date | 12/13/2023
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Last Update Date | 02/06/2024
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Provider Practice Location Address
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Address Line | 551 W LANCASTER AVE
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City | HAVERFORD
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State | PA
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Zip | 19041-1419
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Country | US
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Telephone | 610-710-2020
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Fax | 610-710-2710
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Provider Business Mailing Address
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Address Line | 249 S 7TH ST
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City | PHILADELPHIA
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State | PA
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Zip | 19106-4135
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Country | US
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Telephone | 267-257-1304
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Fax | 816-208-0207
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Authorized Official
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Title or Position | OWNER
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Name | DR. HILARY BRADER
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Credential | MD
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Telephone | 267-257-1304
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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