Provider Demographics
NPI:1336408871
Name:BLAIR ORTHOPEDIC ASSOCIATES, INC
Entity Type:Organization
Organization Name:BLAIR ORTHOPEDIC ASSOCIATES, INC
Other - Org Name:BLAIR ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:PORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-942-1166
Mailing Address - Street 1:3000 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-4472
Mailing Address - Country:US
Mailing Address - Phone:814-942-1166
Mailing Address - Fax:814-942-6222
Practice Address - Street 1:121 JUNE DR
Practice Address - Street 2:
Practice Address - City:ROARING SPRING
Practice Address - State:PA
Practice Address - Zip Code:16673-1209
Practice Address - Country:US
Practice Address - Phone:814-942-1166
Practice Address - Fax:814-942-6222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014338207QS0010X
PAOS015190207QS0010X
PAMD042447L207X00000X
PAOS009814L207X00000X
PAOS010299L207X00000X
PAMD430649207X00000X
PAOS015167208100000X
PASC005969213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA187374J30Medicare PIN
PA025107J30Medicare PIN
PA761950J30Medicare PIN
PA226920J30Medicare PIN
PA155937J30Medicare PIN
PA225480J30Medicare PIN
PA120634J30Medicare PIN
PA764251J30Medicare PIN