Healthcare Provider Details

I. General information

NPI: 1003031816
Provider Name (Legal Business Name): JAMES BLAKELY MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 E WADSWORTH AVE UNIT 1
PHILADELPHIA PA
19150-1617
US

IV. Provider business mailing address

1265 WAYNE AVE STE 308 119 PROFESSIONAL BUILDING
INDIANA PA
15701-3501
US

V. Phone/Fax

Practice location:
  • Phone: 267-323-2778
  • Fax: 267-323-2774
Mailing address:
  • Phone: 724-801-8095
  • Fax: 724-801-8147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number20500
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT015918
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: