Provider Demographics
NPI:1548217003
Name:BUSILLO, NICHOLAS ANTHONY SR (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ANTHONY
Last Name:BUSILLO
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3030 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-2217
Mailing Address - Country:US
Mailing Address - Phone:610-622-7933
Mailing Address - Fax:610-622-7937
Practice Address - Street 1:3030 GARRETT RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-2217
Practice Address - Country:US
Practice Address - Phone:610-622-7933
Practice Address - Fax:610-622-7937
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD022593-E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA067878RNLMedicare PIN