Healthcare Provider Details

I. General information

NPI: 1477538601
Provider Name (Legal Business Name): MARTIN L BLANK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE STR. 6 SILVERSTEIN
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

3400 SPRUCE STR. 6 SILVERSTEIN
PHILADELPHIA PA
19104
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-2050
  • Fax:
Mailing address:
  • Phone: 215-662-2050
  • Fax: 440-879-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD442522
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD442522
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: