Basic Information
| Provider Information | |||||||||
| NPI: | 1508971441 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAIN LINE HOSPITALS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRYN MAWR HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3803 W CHESTER PIKE STE 250 | ||||||||
| Address2: | |||||||||
| City: | NEWTOWN SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190732336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843371814 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 S BRYN MAWR AVE | ||||||||
| Address2: | |||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105263000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | BUONGIORNO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4843378480 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 280701 | PA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0001101000 | 01 | AMERIHEALTH | OTHER | 0001443 | 01 | AETNA | OTHER | 00899789 | 05 | NY | MEDICAID | 60081 | 01 | KEYSTONE MERCY | OTHER | 461415100 | 05 | MD | MEDICAID | 0500157 | 01 | CIGNA | OTHER | 4194705 | 05 | NJ | MEDICAID | 0001101000 | 01 | INDEPENDENCE BLUE CROSS | OTHER | 08307 | 01 | HEALTH PARTNERS | OTHER | 100735428 | 05 | PA | MEDICAID | 258211 | 01 | MAMSI/ALLIANCE PPO | OTHER | A10014 | 01 | FIRST STATE MA MANAGED C | OTHER | 909372900 | 05 | FL | MEDICAID | 0055726101 | 01 | AMERICHOICE | OTHER |