MEDICARE: BLAKE GASTROENTEROLOGY ASSOCIATES, LLC

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	207RG0100X	Gastroenterology Physician	OS007404E	PA

General Provider Information

NPI Number	:	1386729705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAKE GASTROENTEROLOGY ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	6827-31 GERMANTOWN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19119-2113
Country	:	US
Telephone Number	:	215-849-4902
Fax Number	:	215-849-4907

Provider Business Practice Location Address
First Line	:	6827-31 GERMANTOWN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19119-2113
Country	:	US
Telephone Number	:	215-849-4902
Fax Number	:	215-849-4907

Authorized Official
Title or Position	:	CEO
Name	:	JAMES STEVEN BLAKE
Credential	:	DO
Telephone Number	:	215-849-4902

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	06/27/2012

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