Basic Information
| Provider Information | |||||||||
| NPI: | 1053559021 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAIN LINE FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 227 WINSOR LN | ||||||||
| Address2: | |||||||||
| City: | HAVERFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190411822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106427741 | ||||||||
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| Practice Location | |||||||||
| Address1: | 888 GLENBROOK AVE | ||||||||
| Address2: | |||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190102506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105252990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2009 | ||||||||
| LastUpdateDate: | 01/29/2009 | ||||||||
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| AuthorizedOfficialLastName: | HARGROVE | ||||||||
| AuthorizedOfficialFirstName: | CLAUDIA | ||||||||
| AuthorizedOfficialMiddleName: | LIANE | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4849957741 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD 430289 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.