Healthcare Provider Details

I. General information

NPI: 1639538135
Provider Name (Legal Business Name): KEYSTONE EMERGENCY PHYSICIANS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 02/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15425 N GREENWAY HAYDEN LOOP STE A300
SCOTTSDALE AZ
85260-1204
US

IV. Provider business mailing address

PO BOX 98802
LAS VEGAS NV
89193-8802
US

V. Phone/Fax

Practice location:
  • Phone: 469-401-2386
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DONALD GODBOLD, M.D.
Title or Position: OFFICER
Credential:
Phone: 469-401-2386