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General NPI Number Information
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NPI Number | 1902075617
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Entity Type | Organization
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Legal Business Name | KEYSTONE PAIN CENTER LLC
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Dates
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Enumeration Date | 02/27/2008
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Last Update Date | 05/22/2008
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Provider Practice Location Address
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Address Line | 468 NORTHAMPTON ST
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City | EDWARDSVILLE
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State | PA
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Zip | 18704-4566
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Country | US
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Telephone | 570-718-1307
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Fax | 570-718-1309
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Provider Business Mailing Address
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Address Line | 415 N MAIN ST
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City | WILKES BARRE
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State | PA
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Zip | 18702-4411
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Country | US
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Telephone | 570-208-5571
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Fax | 570-208-5548
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DASA SATYAM
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Credential | MD
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Telephone | 570-718-1307
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | MD036737L
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | MD036737L
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License Number State | PA
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