Basic Information
| Provider Information | |||||||||
| NPI: | 1093357923 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAIN LINE WELLNESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S HENDERSON RD STE 308C | ||||||||
| Address2: | |||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194064206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103373111 | ||||||||
| FaxNumber: | 6102331272 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S HENDERSON RD STE 308C | ||||||||
| Address2: | |||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194064206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103373111 | ||||||||
| FaxNumber: | 6102331272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2019 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | LERMAN | ||||||||
| AuthorizedOfficialFirstName: | ROY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 6103373111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ROY M LERMAN MD PC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1234567 | 01 | PA | STARTING CREDENTIALING PROCESS | OTHER |