Basic Information
| Provider Information | |||||||||
| NPI: | 1205815479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TYSON | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | F. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 PLEASANT VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177573537 | ||||||||
| FaxNumber: | 7177189701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 EICHELBERGER ST | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | HANOVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173311374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177573537 | ||||||||
| FaxNumber: | 7177189701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 06/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | SC005821 | PA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | SC005821 | PA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 1021748160001 | 05 | PA | MEDICAID | 50053764 | 01 | PA | CAPITAL BLUE CROSS | OTHER |