Healthcare Provider Details

I. General information

NPI: 1326323098
Provider Name (Legal Business Name): KEYSTONE ORTHOPAEDIC SPECIALISTS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 BROADCASTING RD
WYOMISSING PA
19610-3203
US

IV. Provider business mailing address

1270 BROADCASTING RD
WYOMISSING PA
19610-3203
US

V. Phone/Fax

Practice location:
  • Phone: 610-376-5600
  • Fax: 610-372-7684
Mailing address:
  • Phone: 610-376-5600
  • Fax: 610-372-7684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHEN PATRICK BANCO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 610-372-1140