1104205400 NPI number — RESIDENTIALIST HOUSECALL MED GRP, PC A PENNSYLVANIA CORP

Table of content: (NPI 1104205400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104205400 NPI number — RESIDENTIALIST HOUSECALL MED GRP, PC A PENNSYLVANIA CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESIDENTIALIST HOUSECALL MED GRP, PC A PENNSYLVANIA CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104205400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4190 CITY AVE
Provider Second Line Business Practice Location Address:
PCOM - ROWLAND HALL, ROOM 528
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19131-1626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-366-1053
Provider Business Practice Location Address Fax Number:
949-544-7880
Provider Enumeration Date:
05/20/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WALTON
Authorized Official First Name:
MARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
949-366-1053

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X , with the licence number:  OS017618 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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