Provider Demographics
NPI:1659457760
Name:MT AIRY AMBULATORY ENDOSCOPY SURGERY CENTER
Entity Type:Organization
Organization Name:MT AIRY AMBULATORY ENDOSCOPY SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MEDICAL DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-849-4902
Mailing Address - Street 1:P.O. BOX 5651
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129
Mailing Address - Country:US
Mailing Address - Phone:215-849-4902
Mailing Address - Fax:215-849-4907
Practice Address - Street 1:6827-31 GERMANTOWN AVE
Practice Address - Street 2:
Practice Address - City:PHILADEPPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-2113
Practice Address - Country:US
Practice Address - Phone:215-849-4902
Practice Address - Fax:215-849-4902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2034261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101729710-001Medicaid
PA095897Medicare PIN