Provider Demographics
NPI:1477975647
Name:KEYSTONE MEDICAL, PLLC
Entity Type:Organization
Organization Name:KEYSTONE MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRADHAN-NARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-266-4338
Mailing Address - Street 1:77 CALLE PORTAL
Mailing Address - Street 2:SUITE B260A
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2967
Mailing Address - Country:US
Mailing Address - Phone:520-226-4338
Mailing Address - Fax:520-515-9786
Practice Address - Street 1:77 CALLE PORTAL
Practice Address - Street 2:SUITE B260A
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2967
Practice Address - Country:US
Practice Address - Phone:520-226-4338
Practice Address - Fax:520-515-9786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-07
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32180207R00000X, 310400000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing FacilityGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ897280Medicaid
AZ897280Medicaid