Healthcare Provider Details

I. General information

NPI: 1265476386
Provider Name (Legal Business Name): RICHARD ATWATER BALDERSTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 WALNUT ST SUITE L50
PHILADELPHIA PA
19106-3323
US

IV. Provider business mailing address

PO BOX 8500-1672
PHILADELPHIA PA
19178-1672
US

V. Phone/Fax

Practice location:
  • Phone: 215-409-9300
  • Fax: 215-409-9365
Mailing address:
  • Phone: 215-269-6700
  • Fax: 215-269-6701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberMD020871E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number25MA06837200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: