NPIMap

Organization Active NPI

Residentialist Housecall Med GRP, PC a Pennsylvania Corp

  • Geriatric Medicine (Family Medicine) Physician
  • Philadelphia, PA
National Provider Identifier
1104205400
Registry record updated Mar 5, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Geriatric Medicine (Family Medicine) PhysicianTaxonomy code 207QG0300X
License
OS017618 Issued in PA
Legal business name
RESIDENTIALIST HOUSECALL MED GRP, PC A PENNSYLVANIA CORP
Practice address
4190 City Ave
Pcom - Rowland Hall, Room 528
Philadelphia, PA 19131-1626
Phone
(949) 366-1053
Fax
(949) 544-7880
NPI assigned
May 20, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 5, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Miss Marie Walton
Title
Billing Manager
Phone
(949) 366-1053

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Geriatric Medicine (Family Medicine) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207QG0300X OS017618 PA Primary

Addresses

Primary practice location

4190 City Ave
Pcom - Rowland Hall, Room 528
Philadelphia, PA 19131-1626

Mailing address

3800 Kilroy Airport Way Ste 270
Long Beach, CA 90806-2497
Phone (949) 366-1053

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150825005345 PA Part B Supplier - Clinic/Group Practice 7416263199 Receives reassigned benefits from 18 practitioners
Practice locations: Philadelphia, PA

National Provider Directory

National Provider Directory

Locations

3800 Kilroy Airport Way
Ste 270
Long Beach, CA 90806
Phone (949) 366-1053

Practitioners & affiliated clinicians

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 18

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1432080000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1741132800000",
    "number": "1104205400",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3800 KILROY AIRPORT WAY STE 270",
            "city": "LONG BEACH",
            "state": "CA",
            "postal_code": "908062497",
            "telephone_number": "949-366-1053",
            "fax_number": "949-916-0387"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4190 CITY AVE",
            "address_2": "PCOM - ROWLAND HALL, ROOM 528",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191311626",
            "telephone_number": "949-366-1053",
            "fax_number": "949-544-7880"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RESIDENTIALIST HOUSECALL MED GRP, PC A PENNSYLVANIA CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-05-20",
        "last_updated": "2025-03-05",
        "certification_date": "2025-03-05",
        "status": "A",
        "authorized_official_last_name": "WALTON",
        "authorized_official_first_name": "MARIE",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "949-366-1053",
        "authorized_official_name_prefix": "Miss"
    },
    "taxonomies": [
        {
            "code": "207QG0300X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine, Geriatric Medicine",
            "state": "PA",
            "license": "OS017618",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Philadelphia, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 5, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.