1114559267 NPI number — KEYSTONE COMMUNITY RESOURCES, INC.

Table of content: DR. FADY KHOURY COLLADO M.D. (NPI 1730175357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114559267 NPI number — KEYSTONE COMMUNITY RESOURCES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEYSTONE COMMUNITY RESOURCES, INC.
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:
1114559267
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 ABINGTON EXECUTIVE PARK STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKS SUMMIT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18411-2276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-702-8000
Provider Business Mailing Address Fax Number:
570-702-8096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
336 SHERIDAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKS SUMMIT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18411-1458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-319-1482
Provider Business Practice Location Address Fax Number:
570-702-8096
Provider Enumeration Date:
02/06/2020

Additional Information

Authorized Official

Authorized Official Last Name:
DAVITT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
ACCOUNTS RECEIVABLE COORDINATOR
Authorized Official Telephone Number:
570-702-8000

Provider Taxonomy Codes

  • Taxonomy code: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0598747 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100001010 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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