Basic Information
| Provider Information | |||||||||
| NPI: | 1417963984 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAIN LINE MEDICAL EXERCISE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 931 E HAVERFORD RD | ||||||||
| Address2: | |||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105277870 | ||||||||
| FaxNumber: | 6105272337 | ||||||||
| Practice Location | |||||||||
| Address1: | 931 E HAVERFORD RD | ||||||||
| Address2: | |||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105277870 | ||||||||
| FaxNumber: | 6105272337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | SCHWAB | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6105277870 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0506820000 | 01 | PA | PERSONAL CHOICE | OTHER | 4479578 | 01 | PA | AETNA | OTHER | 450716 | 01 | PA | AETNA HMO | OTHER | 0506820000 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER | 655497 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |