=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902646003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEYSTONE MEDICAL GROUP, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2024
-----------------------------------------------------
Last Update Date | 05/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 CARONDELET DR STE 416
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64114-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-705-2842
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 CARONDELET DR STE 416
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64114-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 167-052-8428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | LANCE STEVENSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 913-486-3196
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------