Provider Demographics
NPI:1659618858
Name:SHIPON-BLUM, ELISA (DO)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:
Last Name:SHIPON-BLUM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 HERKNESS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MEADOWBROOK
Mailing Address - State:PA
Mailing Address - Zip Code:19046
Mailing Address - Country:US
Mailing Address - Phone:215-887-5748
Mailing Address - Fax:215-827-5722
Practice Address - Street 1:505 OLD YORK ROAD
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:JENKNTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046
Practice Address - Country:US
Practice Address - Phone:215-887-5748
Practice Address - Fax:215-827-5722
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-007431-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine