Provider Demographics
NPI:1588107668
Name:BUSTLETON HEALTHCARE
Entity type:Organization
Organization Name:BUSTLETON HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOUKOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-307-9236
Mailing Address - Street 1:9867 BUSTLETON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-2611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9867 BUSTLETON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-2611
Practice Address - Country:US
Practice Address - Phone:215-698-9295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARDIOLOGY CONSULTANTS OF GREATER PHILADELPHIA PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 435017261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102790572 0001Medicaid
PA102790572 0001Medicaid