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General NPI Number Information
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NPI Number | 1659457760
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Entity Type | Organization
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Legal Business Name | MT AIRY AMBULATORY ENDOSCOPY SURGERY CENTER
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Dates
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Enumeration Date | 10/31/2006
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Last Update Date | 06/03/2011
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Provider Practice Location Address
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Address Line | 6827-31 GERMANTOWN AVE
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City | PHILADEPPHIA
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State | PA
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Zip | 19119-2113
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Country | US
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Telephone | 215-849-4902
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Fax | 215-849-4902
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Provider Business Mailing Address
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Address Line | P.O. BOX 5651
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City | PHILADELPHIA
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State | PA
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Zip | 19129
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Country | US
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Telephone | 215-849-4902
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Fax | 215-849-4907
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Authorized Official
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Title or Position | CEO/MEDICAL DIRECTOR/ADMINISTRATOR
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Name | DR. JAMES STEVEN BLAKE
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Credential | DO
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Telephone | 215-849-4902
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 2034
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License Number State | PA
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