1326293523 NPI number — SHELLEY BLAKER PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326293523 NPI number — SHELLEY BLAKER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKER
Provider First Name:
SHELLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326293523
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E OLNEY AVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
PHILA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19120-2421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-456-7000
Provider Business Mailing Address Fax Number:
215-254-3289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5401 OLD YORK RD
Provider Second Line Business Practice Location Address:
WILLOWCREST BLDG, 4TH FL
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19141-3030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-456-3953
Provider Business Practice Location Address Fax Number:
215-456-5948
Provider Enumeration Date:
12/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  MA053673 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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