Provider Demographics
NPI:1780743302
Name:BUSTLETON PHYSICAL & SPORTS REHAB
Entity type:Organization
Organization Name:BUSTLETON PHYSICAL & SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GAVARONE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-676-7067
Mailing Address - Street 1:9622 BUSTLETON AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3100
Mailing Address - Country:US
Mailing Address - Phone:215-677-8258
Mailing Address - Fax:215-673-4966
Practice Address - Street 1:9622 BUSTLETON AVE
Practice Address - Street 2:STE 4
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3100
Practice Address - Country:US
Practice Address - Phone:215-677-8258
Practice Address - Fax:215-673-4966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
039451Medicare ID - Type Unspecified