Basic Information
| Provider Information | |||||||||
| NPI: | 1790192441 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRYN MAWR MEDICAL SPECIALISTS ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 OLD LANCASTER RD | ||||||||
| Address2: | STE 320 | ||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105273800 | ||||||||
| FaxNumber: | 6105270334 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 HAVERFORD RD | ||||||||
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| City: | HAVERFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190411139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105252990 | ||||||||
| FaxNumber: | 6105252099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2014 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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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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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.