Provider Demographics
NPI:1588873558
Name:MAIN LINE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:MAIN LINE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:R
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:610-971-6969
Mailing Address - Street 1:150 STRAFFORD AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-3114
Mailing Address - Country:US
Mailing Address - Phone:610-971-6969
Mailing Address - Fax:610-971-9444
Practice Address - Street 1:150 STRAFFORD AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-3114
Practice Address - Country:US
Practice Address - Phone:610-971-6969
Practice Address - Fax:610-971-9444
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAIN LINE PHYSICAL THERAPY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-22
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA008710-E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA066249Medicare ID - Type Unspecified