MEDICARE: MAIN LINE OPHTHALMOLOGY ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0468327000	OTHER	PA	IBC

General Provider Information

NPI Number	:	1316978810
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN LINE OPHTHALMOLOGY ASSOCIATES

Provider Business Mailing Address
First Line	:	100 CHURCH RD
Second Line	:	SUITE 100
City	:	ARDMORE
State	:	PA
Zip	:	19003-2316
Country	:	US
Telephone Number	:	610-649-7616
Fax Number	:	610-649-6146

Provider Business Practice Location Address
First Line	:	100 CHURCH RD
Second Line	:	SUITE 100
City	:	ARDMORE
State	:	PA
Zip	:	19003-2316
Country	:	US
Telephone Number	:	610-649-7616
Fax Number	:	610-649-6146

Authorized Official
Title or Position	:	DIRECTOR
Name	:	RALPH S SANDO
Credential	:	MD
Telephone Number	:	610-649-7616

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	08/22/2020

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