Basic Information
| Provider Information | |||||||||
| NPI: | 1578222758 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BMMSA HEART & VASCULAR CENTER OF THE MAIN LINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 E HAVERFORD RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105273800 | ||||||||
| FaxNumber: | 6105270334 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 E HAVERFORD RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105273800 | ||||||||
| FaxNumber: | 6105270334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2021 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | MILITELLO | ||||||||
| AuthorizedOfficialFirstName: | RUSS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6105273800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
No ID Information.