Provider Demographics
NPI:1104205400
Name:RESIDENTIALIST HOUSECALL MED GRP, PC A PENNSYLVANIA CORP
Entity type:Organization
Organization Name:RESIDENTIALIST HOUSECALL MED GRP, PC A PENNSYLVANIA CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-366-1053
Mailing Address - Street 1:3800 KILROY AIRPORT WAY STE 270
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2497
Mailing Address - Country:US
Mailing Address - Phone:949-366-1053
Mailing Address - Fax:949-916-0387
Practice Address - Street 1:4190 CITY AVE
Practice Address - Street 2:PCOM - ROWLAND HALL, ROOM 528
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:949-366-1053
Practice Address - Fax:949-544-7880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS017618207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty