Provider Demographics
NPI:1215123732
Name:NEW JERSEY KEYSTONE PHYSICIANS,PA
Entity type:Organization
Organization Name:NEW JERSEY KEYSTONE PHYSICIANS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:DEMETRIOS
Authorized Official - Last Name:PANAGIOTOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-447-3690
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07451-0115
Mailing Address - Country:US
Mailing Address - Phone:201-447-3690
Mailing Address - Fax:201-447-3691
Practice Address - Street 1:1200 E RIDGEWOOD AVE
Practice Address - Street 2:WEST WING, SECOND FLOOR
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3957
Practice Address - Country:US
Practice Address - Phone:201-447-3690
Practice Address - Fax:201-447-3691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MAO7320300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ201973014OtherBUSINESS TAX ID
NJ087299OtherMEDICARE
NJ201973014OtherBUSINESS TAX ID
NJ=========OtherTAX ID
087299Medicare PIN
NJ201973014OtherBUSINESS TAX ID
NJH73079Medicare UPIN