1568099240 NPI number — KEYSTONE PASSIONATE CARE, LLC

Table of content: DR. DAVID ARNOLD ELLBOGEN M.D. (NPI 1982709564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568099240 NPI number — KEYSTONE PASSIONATE CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEYSTONE PASSIONATE CARE, LLC
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:
1568099240
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4709 BUCK RUN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRISBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17110-3265
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-683-9244
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2040 LINGLESTOWN RD STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRISBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17110-9568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-265-6826
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NORDT
Authorized Official First Name:
DEANDRE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
717-683-9244

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1034920650001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".