=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962245076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVAMP - ENCARDIA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2024
-----------------------------------------------------
Last Update Date | 01/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 N BROAD ST STE 201
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19130-4379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-908-9520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 510 N BROAD ST STE 201
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19130-4379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-908-9520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER AND AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | JENNIFER BOYD BALDOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-234-5954
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------