MEDICARE: MR. JAMES BLAKELY MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	20500	MD
2	225100000X	Physical Therapist	PT015918	PA

General Provider Information

NPI Number	:	1003031816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES BLAKELY MPT

Provider Business Mailing Address
First Line	:	1265 WAYNE AVE STE 308
Second Line	:	119 PROFESSIONAL BUILDING
City	:	INDIANA
State	:	PA
Zip	:	15701-3501
Country	:	US
Telephone Number	:	724-801-8095
Fax Number	:	724-801-8147

Provider Business Practice Location Address
First Line	:	1555 E WADSWORTH AVE
Second Line	:	UNIT 1
City	:	PHILADELPHIA
State	:	PA
Zip	:	19150-1617
Country	:	US
Telephone Number	:	267-323-2778
Fax Number	:	267-323-2774

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	02/17/2016

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