Basic Information
| Provider Information | |||||||||
| NPI: | 1851358246 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKSTONE | ||||||||
| FirstName: | BURT | ||||||||
| MiddleName: | ROSS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 UNIVERSITY DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | NEWTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189401873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157105522 | ||||||||
| FaxNumber: | 2157105181 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 LANGHORNE NEWTOWN ROAD | ||||||||
| Address2: | ST MARY MEDICAL CENTER | ||||||||
| City: | LANGHORNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157105900 | ||||||||
| FaxNumber: | 2157106973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 05/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | OS006397E | PA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0011712810011 | 05 | PA | MEDICAID |