Provider Demographics
NPI:1306004510
Name:TEKOLSTE, KEALA RAE (MD)
Entity Type:Individual
Prefix:MS
First Name:KEALA
Middle Name:RAE
Last Name:TEKOLSTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:100 W SPROUL RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-2033
Mailing Address - Country:US
Mailing Address - Phone:610-338-1800
Mailing Address - Fax:610-338-1809
Practice Address - Street 1:100 W SPROUL RD
Practice Address - Street 2:SUITE 120
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-2033
Practice Address - Country:US
Practice Address - Phone:610-338-1800
Practice Address - Fax:610-338-1809
Is Sole Proprietor?:No
Enumeration Date:2008-05-26
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD442674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA224597Medicare PIN