Basic Information
| Provider Information | |||||||||
| NPI: | 1750332003 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY ASSOCIATES OF THE MAIN LINE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 225 | ||||||||
| Address2: | |||||||||
| City: | PAOLI | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193010225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106481000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 255 W LANCASTER AVE | ||||||||
| Address2: | |||||||||
| City: | PAOLI | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193011763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106481000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 11/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | SIMPSON | ||||||||
| AuthorizedOfficialFirstName: | EMMA | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 6106481000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0016175060029 | 05 | PA | MEDICAID |