Provider Demographics
NPI:1215346879
Name:MAINLINE BODYBRAIN&SPINE, P.C.
Entity type:Organization
Organization Name:MAINLINE BODYBRAIN&SPINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:BENAQUISTA DESIPIO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-284-0509
Mailing Address - Street 1:118 CONWAY AVE
Mailing Address - Street 2:
Mailing Address - City:NARBERTH
Mailing Address - State:PA
Mailing Address - Zip Code:19072-2202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 CONWAY AVE
Practice Address - Street 2:
Practice Address - City:NARBERTH
Practice Address - State:PA
Practice Address - Zip Code:19072-2202
Practice Address - Country:US
Practice Address - Phone:215-284-0509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015314208100000X, 2081P0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury MedicineGroup - Multi-Specialty