Organization
MAIN LINE AFFILIATES
Active
Organization
MAIN LINE AFFILIATES
Active
Other names
Main Line Behavioral Health Affiliates
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL J BUONGIORNO (EXEC. VP & CFO)
(484) 337-8481
Entity
Organization
Contact information
Practice address
1 RADNOR CORPORATE CTR, SUITE 400, RADNOR, PA 19087-4515
(610) 254-1450
Mailing address
950 E HAVERFORD RD, SUITE 110, BRYN MAWR, PA 19010-3850
(610) 526-8480
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
103G00000X
Clinical Neuropsychologist
—
—
103T00000X
Psychologist
—
—
103TC0700X
Clinical Psychologist
—
—
103TR0400X
Rehabilitation Psychologist
—
—
2084P0800X
Psychiatry Physician
Primary
—
—
2084P0802X
Addiction Psychiatry Physician
—
—
2084P0804X
Child & Adolescent Psychiatry Physician
—
—
261QM0850X
Adult Mental Health Clinic/Center
—
—
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
151081
PA
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
237078
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0470009
AETNA HMO - BMR PSYCH
—
01
—
0664704000
IBC - BMR PSYCH ASSOC
—
05
—
1007726370011
—
PA
01
—
101823
UNITED - CAD - ADULT PHP
—
01
—
101824
UNITED - CAD ADULT IOP
—
01
—
101825
UNITED - CAD ADOLESCENT
—
01
—
2089834
CIGNA - CAD DREXEL HILL
—
01
—
2089835
CIGNA - CAD EXTON
—
01
—
231200000
MAGELLAN - CAD EXTON
—
01
—
2317419000
IBC - MLA
—
01
—
280110000
MAGELLAN - CAD DREXEL HIL
—
01
—
293195
VALUEOPTIONS - MLA
—
01
—
2983830
AETNA HMO - CAD DREX HILL
—
01
—
2983910
AETNA HMO - CAD EXTON
—
01
—
471443000
MAGELLAN - MLA
—
01
—
7985197
AETNA PPO - MLA
—
Enumeration date
12/19/2006
Last updated
05/18/2016
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