Provider Demographics
NPI:1902075617
Name:KEYSTONE PAIN CENTER LLC
Entity Type:Organization
Organization Name:KEYSTONE PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DASA
Authorized Official - Middle Name:
Authorized Official - Last Name:SATYAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-718-1307
Mailing Address - Street 1:415 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-4411
Mailing Address - Country:US
Mailing Address - Phone:570-208-5571
Mailing Address - Fax:570-208-5548
Practice Address - Street 1:468 NORTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18704-4566
Practice Address - Country:US
Practice Address - Phone:570-718-1307
Practice Address - Fax:570-718-1309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036737L207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021049560001Medicaid
PA123597Medicare PIN