Provider Demographics
NPI:1134935273
Name:EXILUS, BLECK
Entity type:Individual
Prefix:
First Name:BLECK
Middle Name:
Last Name:EXILUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14-20 MACDADE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19023-1822
Mailing Address - Country:US
Mailing Address - Phone:610-522-4506
Mailing Address - Fax:
Practice Address - Street 1:14-20 MACDADE BLVD STE A
Practice Address - Street 2:
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-1822
Practice Address - Country:US
Practice Address - Phone:610-522-4506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP031538363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty