Basic Information
| Provider Information | |||||||||
| NPI: | 1770556615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOTROS | ||||||||
| FirstName: | NAHED | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 S. BRYN MAWR AVE. | ||||||||
| Address2: | SUITE H321 | ||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843374097 | ||||||||
| FaxNumber: | 4843374082 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 S. BRYN MAWR AVE. | ||||||||
| Address2: | SUITE H321 | ||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843374097 | ||||||||
| FaxNumber: | 4843374082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS008307L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | OS008307L | PA | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 001705037 | 05 | PA | MEDICAID | 232359401 | 01 | PA | MAIN LINE HEALTHCARE | OTHER |