Provider Demographics
NPI:1396869012
Name:WESTERN MAIN LINE UROLOGY PC
Entity type:Organization
Organization Name:WESTERN MAIN LINE UROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-644-9600
Mailing Address - Street 1:255 W LANCASTER AVE
Mailing Address - Street 2:SUITE 333
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1763
Mailing Address - Country:US
Mailing Address - Phone:610-644-9600
Mailing Address - Fax:610-644-0804
Practice Address - Street 1:255 W LANCASTER AVE
Practice Address - Street 2:SUITE 333
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1763
Practice Address - Country:US
Practice Address - Phone:610-644-9600
Practice Address - Fax:610-644-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD04339E208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011574150003Medicaid
PA0866534000OtherIBC
PA920504OtherHIGHMARK BS
PA0866534000OtherIBC
PA0011574150003Medicaid