Basic Information
| Provider Information | |||||||||
| NPI: | 1730702820 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KEYSTONE PAIN CONSULTANTS & INTERVENTIONAL SPINE SPECIALISTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 791 | ||||||||
| Address2: | |||||||||
| City: | CARNEGIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151060791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126554362 | ||||||||
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| Practice Location | |||||||||
| Address1: | 80 LANDINGS DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153019408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4129425786 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2020 | ||||||||
| LastUpdateDate: | 06/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BILLINGS | ||||||||
| AuthorizedOfficialFirstName: | KRISTYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4126554362 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD043068L | 01 | PA | STATE LICENSE | OTHER |