Provider Demographics
NPI:1043248271
Name:BOLTON, GREGORY C SR (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:BOLTON
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 E LANCASTER AVE STE 135
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3453
Mailing Address - Country:US
Mailing Address - Phone:610-896-4380
Mailing Address - Fax:484-572-0151
Practice Address - Street 1:100 E LANCASTER AVE STE 135
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3453
Practice Address - Country:US
Practice Address - Phone:610-896-4380
Practice Address - Fax:484-572-0151
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035094L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB35158Medicare UPIN
PA0007539600010Medicaid
PA079089OtherPERSONAL CHOICE
PA2807243OtherAETNA HMO
PA160058156OtherMEDICAL ASSISTANCE
PA0007539600009Medicaid
PA079089QRKMedicare PIN
PA884020OtherUNITED HEALTHCARE
PA810315220OtherPHCS
PA079089OtherBLUE SHIELD
PA1084194OtherKEYSTONE MERCY
PA2807243OtherAETNA PPO
PA0052809000OtherKEYSTONE, IBC
PA1332970OtherFIRST HEALTH
PAB35158Medicare UPIN
PA00753960-02OtherAMERICHOICE
PA0007539600011Medicaid
PA33630OtherHEALTH PARTNERS
PA160058156OtherRAILROAD MEDICARE
PA0007539600012Medicaid