Basic Information
| Provider Information | |||||||||
| NPI: | 1003017534 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROY M LERMAN MD PC | ||||||||
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| OtherOrganizationName: | MAIN LINE SPINE PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S HENDERSON RD | ||||||||
| Address2: | STE 308C | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103373111 | ||||||||
| FaxNumber: | 6103373506 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S HENDERSON RD | ||||||||
| Address2: | STE 300A | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103370427 | ||||||||
| FaxNumber: | 6103373506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 07/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | LERMAN | ||||||||
| AuthorizedOfficialFirstName: | ROY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6103373111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ROY M LERMAN MD PC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 777323 | 01 | PA | BLUE SHIELD HIGHMARK | OTHER |