Healthcare Provider Details

I. General information

NPI: 1578534533
Provider Name (Legal Business Name): SEAN BLAKE REITER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1648 HUNTINGDON PIKE ATTN: RADIOLOGY
MEADOWBROOK PA
19046-8001
US

IV. Provider business mailing address

PO BOX 782743 ATTN: CREDENTIALING
PHILADELPHIA PA
19178-2743
US

V. Phone/Fax

Practice location:
  • Phone: 215-612-2610
  • Fax: 215-612-5077
Mailing address:
  • Phone: 602-910-6887
  • Fax: 215-612-5077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberMD061129L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number25MA07397800
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD061129L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA07397800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: