1477754596 NPI number — KEYSTONE SPINE RESEARCH, SOMATIC STUDIES AND ORTHOPAEDIC THERAPY

Table of content: (NPI 1477754596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477754596 NPI number — KEYSTONE SPINE RESEARCH, SOMATIC STUDIES AND ORTHOPAEDIC THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEYSTONE SPINE RESEARCH, SOMATIC STUDIES AND ORTHOPAEDIC THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477754596
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNIONTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15401-3607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-437-9020
Provider Business Mailing Address Fax Number:
724-437-0295

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIONTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15401-3607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-437-9020
Provider Business Practice Location Address Fax Number:
724-437-0295
Provider Enumeration Date:
05/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LIGHT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
724-437-9020

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4928L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1043386 . This is a "WV WORK COMP PROVIDER" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 351224 . This is a "HIGHMARK BC BS GROUP NO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1539534 . This is a "GATEWAY PROVIDER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1619126 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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