Provider Demographics
NPI:1356406425
Name:KEYSTONE PODIATRIC MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:KEYSTONE PODIATRIC MEDICAL ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ROGER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:717-677-9288
Mailing Address - Street 1:6100 OLD JONESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-2632
Mailing Address - Country:US
Mailing Address - Phone:717-541-0988
Mailing Address - Fax:717-541-8838
Practice Address - Street 1:6100 JONESTOWN RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-2632
Practice Address - Country:US
Practice Address - Phone:717-541-0988
Practice Address - Fax:717-541-8838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016004560013Medicaid
PAT29391Medicare UPIN
PA1149270003Medicare NSC
PAT27688Medicare UPIN
PAV04020Medicare UPIN
PAT72736Medicare UPIN
PAV00289Medicare UPIN
PAU99880Medicare UPIN
PA0016004560013Medicaid