Provider Demographics
NPI:1508222928
Name:FIRST STATE ORTHOPAEDICS, PA
Entity Type:Organization
Organization Name:FIRST STATE ORTHOPAEDICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAEUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-731-2888
Mailing Address - Street 1:211 EXECUTIVE DR STE 11
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-3358
Mailing Address - Country:US
Mailing Address - Phone:302-731-2888
Mailing Address - Fax:
Practice Address - Street 1:642 S QUEEN ST
Practice Address - Street 2:STE 101
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3506
Practice Address - Country:US
Practice Address - Phone:302-731-2888
Practice Address - Fax:302-731-7049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE207X00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE82302Medicaid
DE406917Medicare PIN