Provider Demographics
NPI:1053557082
Name:MAIN LINE GASTROENTEROLOGY ASSOCIATES, PC
Entity type:Organization
Organization Name:MAIN LINE GASTROENTEROLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-723-2333
Mailing Address - Street 1:255 W LANCASTER AVE
Mailing Address - Street 2:PAOLI MEDICAL BUILDING, SUITE 332
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1763
Mailing Address - Country:US
Mailing Address - Phone:610-644-6755
Mailing Address - Fax:610-647-2063
Practice Address - Street 1:255 W LANCASTER AVE
Practice Address - Street 2:PAOLI MEDICAL BUILDING, SUITE 332
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1763
Practice Address - Country:US
Practice Address - Phone:610-644-6755
Practice Address - Fax:610-647-2063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA557861Medicare PIN