Provider Demographics
NPI:1851358246
Name:BLACKSTONE, BURT ROSS (DO)
Entity Type:Individual
Prefix:
First Name:BURT
Middle Name:ROSS
Last Name:BLACKSTONE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:41 UNIVERSITY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1873
Mailing Address - Country:US
Mailing Address - Phone:215-710-5522
Mailing Address - Fax:215-710-5181
Practice Address - Street 1:1201 LANGHORNE NEWTOWN ROAD
Practice Address - Street 2:ST MARY MEDICAL CENTER
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047
Practice Address - Country:US
Practice Address - Phone:215-710-5900
Practice Address - Fax:215-710-6973
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS006397E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011712810011Medicaid
PA0011712810011Medicaid
PA424365Medicare ID - Type Unspecified