Basic Information
| Provider Information | |||||||||
| NPI: | 1841226099 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRYN MAWR MEDICAL SPECIALISTS ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 OLD LANCASTER RD STE 320 | ||||||||
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| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105273800 | ||||||||
| FaxNumber: | 6105270334 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 OLD LANCASTER RD | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105273800 | ||||||||
| FaxNumber: | 6105270608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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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 | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 0048094000 | 01 | PA | GROUP PROV # | OTHER | 0007617390001 | 05 | PA | MEDICAID |