MEDICARE: RESIDENTIALIST HOUSECALL MED GRP, PC A PENNSYLVANIA CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QG0300X	Geriatric Medicine (Family Medicine) Physician	OS017618	PA

General Provider Information

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

Provider Business Mailing Address
First Line	:	3800 KILROY AIRPORT WAY STE 270
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-2497
Country	:	US
Telephone Number	:	949-366-1053
Fax Number	:	949-916-0387

Provider Business Practice Location Address
First Line	:	4190 CITY AVE
Second Line	:	PCOM - ROWLAND HALL, ROOM 528
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-1626
Country	:	US
Telephone Number	:	949-366-1053
Fax Number	:	949-544-7880

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	MISS MARIE WALTON
Credential	:
Telephone Number	:	949-366-1053

Provider Enumeration Date	:	05/20/2015
Last Update Date	:	03/05/2025

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