Healthcare Provider Details

I. General information

NPI: 1689025504
Provider Name (Legal Business Name): SAMIR BHANDUTIA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W TABOR RD FL 4
PHILADELPHIA PA
19141-3019
US

IV. Provider business mailing address

101 E OLNEY AVE STE 400
PHILADELPHIA PA
19120-2470
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-3815
  • Fax: 215-456-6803
Mailing address:
  • Phone: 215-456-1825
  • Fax: 215-456-5926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MB10735400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberOS020669
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberOS020669
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: