Provider Demographics
NPI:1548785801
Name:BMAX PENNSYLVANIA LLC
Entity Type:Organization
Organization Name:BMAX PENNSYLVANIA LLC
Other - Org Name:RENEWED VITALITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:484-516-2937
Mailing Address - Street 1:560 VAN REED RD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1799
Mailing Address - Country:US
Mailing Address - Phone:484-516-2937
Mailing Address - Fax:484-930-0229
Practice Address - Street 1:560 VAN REED RD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1799
Practice Address - Country:US
Practice Address - Phone:484-516-2937
Practice Address - Fax:484-930-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty