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General NPI Number Information
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NPI Number | 1104205400
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Entity Type | Organization
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Legal Business Name | RESIDENTIALIST HOUSECALL MED GRP, PC A PENNSYLVANIA CORP
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Dates
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Enumeration Date | 05/20/2015
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 4190 CITY AVE PCOM - ROWLAND HALL, ROOM 528
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City | PHILADELPHIA
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State | PA
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Zip | 19131-1626
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Country | US
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Telephone | 949-366-1053
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Fax | 949-544-7880
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Provider Business Mailing Address
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Address Line | 3800 KILROY AIRPORT WAY STE 270
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City | LONG BEACH
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State | CA
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Zip | 90806-2497
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Country | US
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Telephone | 949-366-1053
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Fax | 949-916-0387
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | MISS MARIE WALTON
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Credential |
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Telephone | 949-366-1053
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | OS017618
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License Number State | PA
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