MEDICARE: MAIN LINE DERMATOLOGY, INC.

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	174400000X	Specialist

General Provider Information

NPI Number	:	1497787246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN LINE DERMATOLOGY, INC.

Provider Business Mailing Address
First Line	:	995 OLD EAGLE SCHOOL RD
Second Line	:	SUITE 304-F
City	:	WAYNE
State	:	PA
Zip	:	19087-1709
Country	:	US
Telephone Number	:	610-688-3099
Fax Number	:	610-687-5350

Provider Business Practice Location Address
First Line	:	995 OLD EAGLE SCHOOL RD
Second Line	:	SUITE 304-F
City	:	WAYNE
State	:	PA
Zip	:	19087-1709
Country	:	US
Telephone Number	:	610-688-3099
Fax Number	:	610-687-5350

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	LORETTA R KRAMER
Credential	:
Telephone Number	:	610-688-3099

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	08/22/2020

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