Healthcare Provider Details

I. General information

NPI: 1336408871
Provider Name (Legal Business Name): BLAIR ORTHOPEDIC ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 JUNE DR
ROARING SPRING PA
16673-1209
US

IV. Provider business mailing address

3000 FAIRWAY DR
ALTOONA PA
16602-4472
US

V. Phone/Fax

Practice location:
  • Phone: 814-942-1166
  • Fax: 814-942-6222
Mailing address:
  • Phone: 814-942-1166
  • Fax: 814-942-6222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS014338
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS015190
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD042447L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOS009814L
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOS010299L
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD430649
License Number StatePA
# 7
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOS015167
License Number StatePA
# 8
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC005969
License Number StatePA

VIII. Authorized Official

Name: DR. JOSHUA PORT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 814-942-1166