Provider Demographics
NPI:1356399075
Name:GORTI, SUBBARAO (MD)
Entity type:Individual
Prefix:
First Name:SUBBARAO
Middle Name:
Last Name:GORTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1648 HUNTINGDON PIKE
Mailing Address - Street 2:MEDICAL STAFF OFFICE 1ST FLR
Mailing Address - City:MEADOWBROOK
Mailing Address - State:PA
Mailing Address - Zip Code:19046-8001
Mailing Address - Country:US
Mailing Address - Phone:215-938-3450
Mailing Address - Fax:215-938-3829
Practice Address - Street 1:3300 TILLMAN DR
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-2071
Practice Address - Country:US
Practice Address - Phone:215-914-4444
Practice Address - Fax:215-245-2073
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD048575L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0013058950006Medicaid
PA01305895-02OtherAMERICHOICE
PA1022053OtherKEYSTONE MERCY
PA1024550OtherUNITED HEALTHCARE
PA0013058920001Medicaid
PA186650OtherHIGHMARK BLUE SHIELD
PA3832822OtherCIGNA
PA0279193000OtherIBC,KEYSTONE
PA0013058950002Medicaid
PA080105711OtherRAILROAD MEDICARE
PA8696OtherCLEAR CARE
PA810159612OtherPHCS
PAPA0049853OtherTRICARE
PA118031OtherAETNA
PA080105711OtherRAILROAD MEDICARE
PA0013058950006Medicaid