Healthcare Provider Details

I. General information

NPI: 1790782605
Provider Name (Legal Business Name): SAMUEL CHARLES BLACKMAN MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 10/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34TH & CIVIC CENTER BLVD CHILDREN'S HOSPITAL OF PHILADELPHIA
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

100 N 20TH ST STE 301 CHCA
PHILADELPHIA PA
19103-1454
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1000
  • Fax:
Mailing address:
  • Phone: 215-567-2422
  • Fax: 215-977-8864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD433904
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number220358
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberMD433904
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: