MEDICARE: OLIVER C. BULLOCK DO

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	207Q00000X	Family Medicine Physician	OS004271L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184625865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVER C. BULLOCK DO

Provider Business Mailing Address
First Line	:	2100 W CAMBRIA ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-2632
Country	:	US
Telephone Number	:	215-578-3300
Fax Number	:	215-578-3335

Provider Business Practice Location Address
First Line	:	2100 W CAMBRIA ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-2632
Country	:	US
Telephone Number	:	215-578-3300
Fax Number	:	215-578-3335

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	04/08/2009

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Directions to “ OLIVER C. BULLOCK DO” Practice Location

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