=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437363512
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MT. AIRY ANESTHESIOLOGY ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 06/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6827-31 GERMANTOWN AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19119-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-849-4902
-----------------------------------------------------
Fax | 215-849-4902
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 5651
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-849-4902
-----------------------------------------------------
Fax | 215-849-4907
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. JAMES STEVEN BLAKE
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 215-849-4902
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------