Basic Information
| Provider Information | |||||||||
| NPI: | 1598741126 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARNIVALE | ||||||||
| FirstName: | BRUCE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 W HUNTING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073008 | ||||||||
| FaxNumber: | 2157071387 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 N BROAD ST | ||||||||
| Address2: | 7TH FLOOR OUT PATIENT BUILDING | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073008 | ||||||||
| FaxNumber: | 2157071387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 03/21/2017 | ||||||||
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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 | 207V00000X | OS 007278L | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 4476096 | 01 | PA | AETNA PPO | OTHER | 045941 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 3122336 | 01 | PA | AETNA HMO | OTHER | 0678844 | 01 | PA | CIGNA | OTHER | 1016307 | 01 | PA | KEYSTONE MERCY HEALTH PLA | OTHER | 597586 | 01 | PA | MEDICARE GROUP TPI | OTHER | 0146198902 | 01 | PA | AMERICHOICE | OTHER | 001461989 | 05 | PA | MEDICAID | 0717488000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | CD4829 | 01 | PA | RR MEDICARE TPI GROUPS | OTHER | P00025012 | 01 | PA | RAIL ROAD MEDICARE | OTHER |