Provider Demographics
NPI: | 1891085254 |
---|---|
Name: | KELLER-SMITH, AMANDA LINDSAY (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | AMANDA |
Middle Name: | LINDSAY |
Last Name: | KELLER-SMITH |
Suffix: | |
Gender: | F |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3421 CONCORD RD |
Mailing Address - Street 2: | |
Mailing Address - City: | YORK |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 17402-9001 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 717-851-4005 |
Mailing Address - Fax: | 717-812-2495 |
Practice Address - Street 1: | 1001 S GEORGE ST FL 4 |
Practice Address - Street 2: | |
Practice Address - City: | YORK |
Practice Address - State: | PA |
Practice Address - Zip Code: | 17403-3676 |
Practice Address - Country: | US |
Practice Address - Phone: | 717-851-4005 |
Practice Address - Fax: | 717-812-2495 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2011-04-19 |
Last Update Date: | 2022-05-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | OS016703 | 207Q00000X, 208M00000X |
PA | OT013979 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 102952080 - 0001 | Medicaid | |
PA | P01418537 | Medicare PIN | |
PA | 362009FLT | Medicare PIN |