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NPI Code Detail

MEDICARE: BLAKE SHORE

MEDICARE: BLAKE SHORE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1215867841
Entity Type Code : Individual
Provider Name (Legal Business Name) : BLAKE SHORE
Provider Business Mailing Address
First Line : 240 S 40TH ST
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19104-6030
Country : US
Telephone Number : 215-573-2588
Fax Number :
Provider Business Practice Location Address
First Line : 240 S 40TH ST
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19104-6030
Country : US
Telephone Number : 215-573-2588
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/25/2026
Last Update Date : 05/25/2026

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Directions to “ BLAKE SHORE ” Practice Location

Language Start Address Practice Location
These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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