Provider Demographics
NPI:1316919368
Name:MAIN LINE EMERGENCY MED ASSOCIATES LLC
Entity type:Organization
Organization Name:MAIN LINE EMERGENCY MED ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAMBURG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-456-4629
Mailing Address - Street 1:PO BOX 415751
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5751
Mailing Address - Country:US
Mailing Address - Phone:866-960-6774
Mailing Address - Fax:
Practice Address - Street 1:255 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1763
Practice Address - Country:US
Practice Address - Phone:610-648-1043
Practice Address - Fax:610-648-1415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0001019000OtherIBC
PA173870000OtherKEYSTONE HEALTH EAST
PA191510OtherPERSONAL CHOICE
PA0001107000OtherIBC
PA0001101000OtherIBC
PA0016139730026Medicaid
PA20020291OtherAMERIHEALTH MERCY
PA191510OtherBLUE SHIELD
PA0016139730025Medicaid
PA1043495OtherKEYSTONE MERCY
PA0016139730024Medicaid
PA191510OtherBLUE SHIELD
PA173870000OtherKEYSTONE HEALTH EAST