Provider Demographics
NPI:1861576753
Name:MEDICAL CENTER OF BUSTLETON PC
Entity type:Organization
Organization Name:MEDICAL CENTER OF BUSTLETON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GAVARONE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-673-7067
Mailing Address - Street 1:9622 BUSTLETON AVENUE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3100
Mailing Address - Country:US
Mailing Address - Phone:215-673-7067
Mailing Address - Fax:215-673-4966
Practice Address - Street 1:9622 BUSTLETON AVENUE
Practice Address - Street 2:SUITE 6
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3100
Practice Address - Country:US
Practice Address - Phone:215-673-7067
Practice Address - Fax:215-673-4966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015772220005Medicaid