Provider Demographics
NPI:1336322775
Name:KEYSTONE MEDICAL SERVICES OF MISSISSIPPI, PA
Entity Type:Organization
Organization Name:KEYSTONE MEDICAL SERVICES OF MISSISSIPPI, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEOPHILUS
Authorized Official - Middle Name:
Authorized Official - Last Name:OKEKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-482-1070
Mailing Address - Street 1:PO BOX 281030
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1030
Mailing Address - Country:US
Mailing Address - Phone:904-482-1070
Mailing Address - Fax:904-482-1076
Practice Address - Street 1:233 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-2228
Practice Address - Country:US
Practice Address - Phone:601-894-4541
Practice Address - Fax:904-482-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09403285Medicaid
MSC04505Medicare PIN