Provider Demographics
NPI:1154512432
Name:PHYSICIANS CARE OF KEYSTONE
Entity Type:Organization
Organization Name:PHYSICIANS CARE OF KEYSTONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:RESTEA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-473-7288
Mailing Address - Street 1:6542 TRIEST AVE
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE HEIGHTS
Mailing Address - State:FL
Mailing Address - Zip Code:32656-9393
Mailing Address - Country:US
Mailing Address - Phone:352-473-7288
Mailing Address - Fax:352-473-9365
Practice Address - Street 1:6542 TRIEST AVE
Practice Address - Street 2:
Practice Address - City:KEYSTONE HEIGHTS
Practice Address - State:FL
Practice Address - Zip Code:32656-9393
Practice Address - Country:US
Practice Address - Phone:352-473-7288
Practice Address - Fax:352-473-9365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0049847207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0694Medicare PIN