Healthcare Provider Details

I. General information

NPI: 1104205400
Provider Name (Legal Business Name): RESIDENTIALIST HOUSECALL MED GRP, PC A PENNSYLVANIA CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 CITY AVE PCOM - ROWLAND HALL, ROOM 528
PHILADELPHIA PA
19131-1626
US

IV. Provider business mailing address

3800 KILROY AIRPORT WAY STE 270
LONG BEACH CA
90806-2497
US

V. Phone/Fax

Practice location:
  • Phone: 949-366-1053
  • Fax: 949-544-7880
Mailing address:
  • Phone: 949-366-1053
  • Fax: 949-916-0387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberOS017618
License Number StatePA

VIII. Authorized Official

Name: MISS MARIE WALTON
Title or Position: BILLING MANAGER
Credential:
Phone: 949-366-1053