Provider Demographics
NPI:1669651527
Name:BULSON, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BULSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 GEORGETOWNE CT
Mailing Address - Street 2:
Mailing Address - City:ROYERSFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19468-3128
Mailing Address - Country:US
Mailing Address - Phone:215-510-0259
Mailing Address - Fax:
Practice Address - Street 1:3551 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4160
Practice Address - Country:US
Practice Address - Phone:215-430-4116
Practice Address - Fax:215-430-4123
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT012615L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist