Healthcare Provider Details

I. General information

NPI: 1659457760
Provider Name (Legal Business Name): MT AIRY AMBULATORY ENDOSCOPY SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6827-31 GERMANTOWN AVE
PHILADEPPHIA PA
19119-2113
US

IV. Provider business mailing address

P.O. BOX 5651
PHILADELPHIA PA
19129
US

V. Phone/Fax

Practice location:
  • Phone: 215-849-4902
  • Fax: 215-849-4902
Mailing address:
  • Phone: 215-849-4902
  • Fax: 215-849-4907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number2034
License Number StatePA

VIII. Authorized Official

Name: DR. JAMES STEVEN BLAKE
Title or Position: CEO/MEDICAL DIRECTOR/ADMINISTRATOR
Credential: DO
Phone: 215-849-4902