Provider Demographics
NPI:1265476386
Name:BALDERSTON, RICHARD ATWATER (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ATWATER
Last Name:BALDERSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8500-1672
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-1672
Mailing Address - Country:US
Mailing Address - Phone:215-269-6700
Mailing Address - Fax:215-269-6701
Practice Address - Street 1:601 WALNUT ST
Practice Address - Street 2:SUITE L50
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3323
Practice Address - Country:US
Practice Address - Phone:215-409-9300
Practice Address - Fax:215-409-9365
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020871E207XS0117X
NJ25MA06837200207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0052425000OtherI.B.C.
PA2069868OtherAETNA
PA2069868OtherAETNA
NJ045444Medicare ID - Type Unspecified
PAB41599Medicare UPIN