Basic Information
| Provider Information | |||||||||
| NPI: | 1548419021 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOMBONATI | ||||||||
| FirstName: | ALESSANDRO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500-8735 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191788735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567000 | ||||||||
| FaxNumber: | 2152542599 | ||||||||
| Practice Location | |||||||||
| Address1: | 5501 OLD YORK RD | ||||||||
| Address2: | TOWER BLDG | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154566157 | ||||||||
| FaxNumber: | 2154566426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 09/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | MT185329 | PA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | MD436819 | PA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 0265896 | 05 | NJ | MEDICAID | 102610567 | 05 | PA | MEDICAID |