NPIMap

Organization Active NPI

Medical Center of Bustleton PC

  • Internal Medicine Physician
  • Philadelphia, PA
National Provider Identifier
1861576753
Registry record updated Jun 29, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
MEDICAL CENTER OF BUSTLETON PC
Practice address
9622 Bustleton Avenue
Suite 6
Philadelphia, PA 19115-3100
Phone
(215) 673-7067
Fax
(215) 673-4966
NPI assigned
Oct 25, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 29, 2010

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

Authorized official

Name
Donna Marie Gavarone, DONPI 1881640738
Title
President Owner
Phone
(215) 673-7067

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X Primary

Addresses

Primary practice location

9622 Bustleton Avenue
Suite 6
Philadelphia, PA 19115-3100

Mailing address

9622 Bustleton Avenue
Suite 6
Philadelphia, PA 19115-3100
Phone (215) 673-7067

Other identifiers 1

IdentifierTypeStateIssuer
0015772220005MedicaidPA

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040617001231 PA Part B Supplier - Clinic/Group Practice 8123002912 Receives reassigned benefits from 4 practitioners
Practice locations: Philadelphia, PA

National Provider Directory

National Provider Directory

Locations

9622 Bustleton Ave
Ste 6
Philadelphia, PA 19115
Phone (215) 673-2334

9622 Bustleton Ave
Philadelphia, PA 19115
Phone (215) 698-9200

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1161734400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1277769600000",
    "number": "1861576753",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9622 BUSTLETON AVENUE",
            "address_2": "SUITE 6",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191153100",
            "telephone_number": "215-673-7067",
            "fax_number": "215-673-4966"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9622 BUSTLETON AVENUE",
            "address_2": "SUITE 6",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191153100",
            "telephone_number": "215-673-7067",
            "fax_number": "215-673-4966"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDICAL CENTER OF BUSTLETON PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-25",
        "last_updated": "2010-06-29",
        "status": "A",
        "authorized_official_last_name": "GAVARONE",
        "authorized_official_first_name": "DONNA",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "PRESIDENT OWNER",
        "authorized_official_telephone_number": "215-673-7067",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0015772220005",
            "state": "PA"
        }
    ],
    "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 Jun 29, 2010; 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.