=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780833970
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMMAD M KEYKHAH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2008
-----------------------------------------------------
Last Update Date | 04/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 N 15TH ST # MS 310
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19102-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-762-4312
-----------------------------------------------------
Fax | 215-762-8656
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21127 VALLEY FORGE CIR
-----------------------------------------------------
City | KING OF PRUSSIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19406-1198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-762-4312
-----------------------------------------------------
Fax | 215-762-8656
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | MD035173L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------