Provider Demographics
NPI:1154991495
Name:BARTUSEK, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:BARTUSEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4054 MARLBERRY LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-8417
Mailing Address - Country:US
Mailing Address - Phone:321-505-1509
Mailing Address - Fax:
Practice Address - Street 1:1015 W BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390-9459
Practice Address - Country:US
Practice Address - Phone:484-429-2351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMA06862207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program