Provider Demographics
NPI:1083898787
Name:KEYSTONE MOBILE PARTNERS, LP
Entity Type:Organization
Organization Name:KEYSTONE MOBILE PARTNERS, LP
Other - Org Name:KEYSTONE KIDNEY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC. DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DERNOGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-675-9900
Mailing Address - Street 1:2701 BLAIR MILL RD
Mailing Address - Street 2:STE. 30
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1041
Mailing Address - Country:US
Mailing Address - Phone:215-675-9900
Mailing Address - Fax:215-675-4096
Practice Address - Street 1:2701 BLAIR MILL RD
Practice Address - Street 2:STE. 30
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1041
Practice Address - Country:US
Practice Address - Phone:215-675-9900
Practice Address - Fax:215-675-4096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA15331501261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical