Basic Information
| Provider Information | |||||||||
| NPI: | 1104205400 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RESIDENTIALIST HOUSECALL MED GRP, PC A PENNSYLVANIA CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23181 VERDUGO DR | ||||||||
| Address2: | SUITE 103A | ||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926531357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493661053 | ||||||||
| FaxNumber: | 9495447880 | ||||||||
| Practice Location | |||||||||
| Address1: | 4190 CITY AVE | ||||||||
| Address2: | PCOM - ROWLAND HALL, ROOM 528 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191311626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493661053 | ||||||||
| FaxNumber: | 9495447880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2015 | ||||||||
| LastUpdateDate: | 06/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | VINN | ||||||||
| AuthorizedOfficialFirstName: | NORMAN | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO, CFO, AND SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9493661053 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | OS017618 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
No ID Information.