Basic Information
| Provider Information | |||||||||
| NPI: | 1326146226 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAIN LINE HAND CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 W LANCASTER AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | PAOLI | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193011743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106518282 | ||||||||
| FaxNumber: | 6106518213 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 W LANCASTER AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | PAOLI | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193011743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106518282 | ||||||||
| FaxNumber: | 6106518213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 08/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | MORRIS | ||||||||
| AuthorizedOfficialFirstName: | ROBERTA | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6106518282 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | OTRL CHR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251H1200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand | 225XH1200X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 3207843 | 01 | AETNA PPO | OTHER | 2116515000 | 01 | PERSONAL CHOICE ROBERTA M | OTHER | 2116418000 | 01 | KEYSTONE HPE KEYSTONE 65 | OTHER | 0401979000 | 01 | PERSONAL CHOICE 65 TERI S | OTHER | P00122385 | 01 | MEDICARE RAILROAD | OTHER | 2627004000 | 01 | PERSONAL CHOICE 65 KATHY | OTHER |