Provider Demographics
NPI:1780817452
Name:KEYSTONE WSNC LLC
Entity Type:Organization
Organization Name:KEYSTONE WSNC LLC
Other - Org Name:OLD VINEYARD PHYSICIAN GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:FILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-768-3300
Mailing Address - Street 1:3637 OLD VINEYARD RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4842
Mailing Address - Country:US
Mailing Address - Phone:336-794-3550
Mailing Address - Fax:336-794-4339
Practice Address - Street 1:3637 OLD VINEYARD RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104
Practice Address - Country:US
Practice Address - Phone:336-794-3550
Practice Address - Fax:336-794-4339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-28
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHH01882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912567Medicaid
2347810Medicare Oscar/Certification