MEDICARE: DR. MOHAN GURUBHAGAVATULA 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	207RR0500X	Rheumatology Physician	OS012602	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GU1507200	OTHER	PA	PIN NUMBER

General Provider Information

NPI Number	:	1467423624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MOHAN GURUBHAGAVATULA DO

Provider Business Mailing Address
First Line	:	225 E CITY AVE STE 215
Second Line	:
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-1704
Country	:	US
Telephone Number	:	610-664-8200
Fax Number	:	866-267-4029

Provider Business Practice Location Address
First Line	:	225 E CITY AVE STE 215
Second Line	:
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-1704
Country	:	US
Telephone Number	:	610-664-8200
Fax Number	:	866-267-4029

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

Provider Enumeration Date	:	01/27/2006
Last Update Date	:	07/29/2025

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